347 Test 3 Prep U
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? Headache and nuchal rigidity Hyporeflexia in the lower extremities Ptosis and diplopia Numbness and vomiting
Headache and nuchal rigidity
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Complete a head-to-toe assessment. Elevate the head of the bed. Administer morning dose of anticonvulsant. Administer Percocet as ordered.
Elevate the head of the bed.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? Eltrombopag GM-CSF Thrombopoietin Erythropoietin
Erythropoietin
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan? Anxiety Body image disturbance Impaired cognition Knowledge deficit
Knowledge deficit
A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason? Preparation for likely nephrectomy Increases the effectiveness of dialysis Lack of erythropoietin Hypervolemia
Lack of erythropoietin
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? Assessment of pupillary light reflexes Maintenance of a patent airway Positioning to prevent complications Determination of the cause
Maintenance of a patent airway
The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? Polycythemia vera Sickle cell disease Aplastic anemia Pernicious anemia
Polycythemia vera
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? Negative Brudzinski's sign Hyper-alertness Positive Romberg sign Positive Kernig's sign
Positive Kernig's sign
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? Carries message to the next nerve cell Speeds nerve impulse transmission Represents building block of nervous system Acts as chemical messenger
Speeds nerve impulse transmission
A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept? Total blood cell count Histology of tissue Staging of disease Involvement of lymph nodes
Staging of disease
What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)? The client has hemorrhoidal bleeding The client regularly takes aspirin The client took an ibuprofen tablet this morning The client had a hamburger for dinner the night before
The client has hemorrhoidal bleeding
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every hour. 24 hours. shift. 12 hours.
shift
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? "I'll report your concerns to the physician." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "There's no other option but to assume the knee-chest position." "Lying on your left side will be fine during the procedure."
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
Which client is not a candidate to be a blood donor according to the American Red Cross? 50-year-old female with pulse 95 beats/minute 86-year-old male with blood pressure 110/70 mm Hg 26-year-old female with hemoglobin 11.0 g/dL 18-year-old male weighing 52 kg
26-year-old female with hemoglobin 11.0 g/dL
The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? Assist the client to a Fowler's position. Prepare for a prostate examination. Ask the client to empty the bladder. Dim the lights for privacy.
Ask the client to empty the bladder.
What part of the brain controls and coordinates muscle movement? Cerebellum Cerebrum Midbrain Brain stem
Cerebellum
Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? Diffuse axonal injury Contusion Intracranial hemorrhage Concussion
Contusion
A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)? Cryptogenic Cardiogenic embolic Small artery thrombotic Large artery thrombotic
Cryptogenic
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count Decreased level of erythropoietin
Decreased level of erythropoietin
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? Taking iron pills with milk aids in absorption. Take iron with an antacid to avoid stomach upset. Avoid vitamin C as it prevents absorption. Drink liquid iron preparations with a straw.
Drink liquid iron preparations with a straw.
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? Clustering of platelets with sickled red blood cells Erythrocytes that are microcytic and hypochromic Erythrocytes that are macrocytic and hyperchromic An increased number of erythrocytes
Erythrocytes that are microcytic and hypochromic
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Gastroesophageal reflux disease Gastritis Esophageal tumor Hiatal hernia
Esophageal tumor
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? Hypermagnesemia Hyperkalemia Hypernatremia Hypercalcemia
Hypercalcemia
A client with a brain tumor experiences projectile vomiting. The nurse integrates understanding of this occurrence as resulting from which of the following? Distortion of pain-sensitive structures Edema associated with the tumor Compression of surrounding structures Irritation of the medullary vagal centers
Irritation of the medullary vagal centers
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? Ischemic Hemorrhagic Right-sided Left-sided
Ischemic
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Kidney Pancreas Large intestine Liver
Liver
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Opening the patient's jaw and inserting a mouth gag Restraining the patient to avoid self injury Loosening constrictive clothing Providing for privacy Positioning the patient on his or her side with head flexed forward
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy
Which term refers to a form of white blood cell involved in immune response? Granulocyte Thrombocyte Spherocyte Lymphocyte
Lymphocyte
The nurse is completing a pretransfusion assessment to determine a female client's history of previous transfusions as well as previous reactions to transfusions. Which is the mostimportant information to obtain from this client before the transfusion? Diagnosis Number of pregnancies Age Family history of transfusion reactions
Number of pregnancies
A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Cephalexin Acyclovir Fluocinolone acetonide oral base gel Nystatin
Nystatin
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Obesity Osteoarthritis Osteoporosis Anemia
Osteoporosis
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Cerebral Epidural Intracerebral Subdural
Subdural
The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for? Basophils Plasma cells T lymphocytes Monocytes
T lymphocytes
Which statement best describes the function of stem cells in the bone marrow? They produce antibodies against foreign antigens. They produce all blood cells. They are active against hypersensitivity reactions. They defend against bacterial infection.
They produce all blood cells.
A client with sickle cell anemia has a low hematocrit. high hematocrit. normal blood smear. normal hematocrit.
low hematocrit.
Corticosteroids are used in the management of brain tumors to facilitate regeneration of neurons. reduce cerebral edema. identify precise location of the tumor. prevent extension of the tumor.
reduce cerebral edema.
The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? "Chronic leukemia develops slowly." "In chronic leukemia, the minority of leukocytes are mature." "Acute leukemia develops slowly." "In acute leukemia there are not many undifferentiated cells."
"Chronic leukemia develops slowly."
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? "Have you developed any new allergies in the last year?" "Have you experienced any viral infections in the last month?" "Have you had difficulty with urination in the last 6 weeks?" "Have you experienced any ptosis in the last few weeks?"
"Have you experienced any viral infections in the last month?"
To help assess a client's cerebral function, a nurse should ask: "Have you had any problems with coordination?" "Have you noticed a change in your memory?" "Have you noticed a change in your muscle strength?" "Have you had any problems with your eyes?"
"Have you noticed a change in your memory?"
A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse? "I'll see a genetic counselor before starting a family." "I need to learn how to give myself vitamin B12 injections." "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children." "Thalassemia is treated with iron supplements."
"I'll see a genetic counselor before starting a family."
A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client? "These symptoms are not related to your past diagnosis." "This will pass, you need to relax." "Intravenous immunoglobulin infusion may help you." "Once you sleep, you should be fine."
"Intravenous immunoglobulin infusion may help you."
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I need to remain active for as long as possible." "My children are at greater risk to develop this disease." "I will lose strength in my arms." "I will have progressive muscle weakness."
"My children are at greater risk to develop this disease."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "You'll first regain use of your legs and then your arms." "The paralysis caused by this disease is temporary." "It must be hard to accept the permanency of your paralysis." "You'll be permanently paralyzed; however, you won't have any sensory loss."
"The paralysis caused by this disease is temporary."
A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following? "The surgeon will be able to remove all of the tumor." "There will be less cancer left that might be resistant to chemotherapy." "Any tissue that was dead will be removed." "My headache and nausea should be lessened somewhat."
"The surgeon will be able to remove all of the tumor."
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response? "Treatment really doesn't matter; the disease is going to progress anyway." "Treatment aims at keeping you independent as long as possible." "Treatment for Parkinson's is only palliative; it keeps you comfortable." "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease."
"Treatment aims at keeping you independent as long as possible."
Upon hearing that the small intestine lining has thinned, an elderly client asks, "What can this lead to?" What is the best response by the nurse? "You may frequently experience constipation." "It is the aging process." "You may frequently have diarrhea." "At times you may see mucus in your stool."
"You may frequently experience constipation."
A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? 2:00 pm 4:00 pm 6:00 pm 3:00 pm
4:00 pm
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Elevated temperature. Bright red venous blood. Decreased oxygen level. Increased bruising.
Decreased oxygen level.
The earliest sign of serious impairment of brain circulation related to increased ICP is: A change in consciousness. Hypertension. Bradycardia. A bounding pulse.
A change in consciousness.
The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood? A donor who is taking medication for benign prostatic hyperplasia A donor who was in college in England for 1 year A donor with a history of hypertension with a blood pressure of 140/90 mm Hg A donor who moved to the United States from Canada
A donor who was in college in England for 1 year
A client with quadriplegia is in spinal shock. What finding should the nurse expect? Spasticity of all four extremities Positive Babinski's reflex along with spastic extremities Absence of reflexes along with flaccid extremities Hyperreflexia along with spastic extremities
Absence of reflexes along with flaccid extremities
Which of the following is the primary function of the small intestine? Peristalsis Absorption Digestion Secretion
Absorption
Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine GABA Acetylcholine
Acetylcholine
Which term refers to the failure to recognize familiar objects perceived by the senses? Perseveration Agnosia Apraxia Agraphia
Agnosia
Which term refers to the inability to recognize objects through a particular sensory system? Dementia Aphasia Agnosia Ataxia
Agnosia
the plasma protein responsible for maintaining oncotic pressure, which is: Globulin. Prothrombin. Albumin. Fibrinogen.
Albumin
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? Encourage the client to close his eyes. Alternatively patch one eye every 2 hours. Turn out the lights in the room. Instill artificial tears.
Alternatively patch one eye every 2 hours.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A partial seizure A tonic-clonic seizure An absence seizure A complex seizure
An absence seizure
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An extradural hematoma A subdural hematoma An epidural hematoma An intracerebral hematoma
An intracerebral hematoma
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? Carotid endarterectomy Anticoagulant therapy Cholesterol-lowering drugs Monthly prothrombin levels
Anticoagulant therapy
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? Implement neutropenic precautions. Apply prolonged pressure to needle sites or other sources of external bleeding. Monitor temperature at least once per shift. Eliminate direct contact with others who are infectious.
Apply prolonged pressure to needle sites or other sources of external bleeding.
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Assess lung sounds bilaterally. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client. Administer prescribed morphine intravenously.
Assess lung sounds bilaterally.
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Autonomic dysreflexia Spinal shock Concussion Contusion
Autonomic dysreflexia
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Consume foods containing peppermint or spearmint. Eat a low-carbohydrate diet. Avoid eating or drinking 2 hours before bedtime. Elevate the foot of the bed on 6- to 8-inch blocks.
Avoid eating or drinking 2 hours before bedtime.
Which positions is used to help reduce intracranial pressure (ICP)? Avoiding flexion of the neck with use of a cervical collar Rotating the neck to the far right with neck support Keeping the head flat, avoiding the use of a pillow Extreme hip flexion, with the hip supported by pillows
Avoiding flexion of the neck with use of a cervical collar
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Dairy products Beans, dried fruits, and leafy, green vegetables Fruits high in vitamin C, such as oranges and grapefruits Berries and orange vegetables
Beans, dried fruits, and leafy, green vegetables
The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? Being an athlete Alcohol/drug use Male gender Young age
Being an athlete
Which clinical manifestation is not associated with hemorrhage? Bradycardia Tachycardia Hypotension Tachypnea
Bradycardia
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? Burr holes Hypophysectomy Application of Halo traction Insertion of Crutchfield tongs
Burr holes
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Turned onto the operative side Elevated 30 degrees Flat Elevated no more than 10 degrees
Elevated 30 degrees
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Renal transplantation Essential thrombocythemia Extreme leukocytosis Sickle cell anemia
Essential thrombocythemia
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: The patient cannot experience the deprivational stress of not swallowing. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Feedings can be administered with the patient in the recumbent position.
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Cushing response Monro-Kellie hypothesis Autoregulation Herniation
Herniation
A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order? CBC chest radiograph ECG antibiotic
CBC
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Cardiogenic emboli Large artery thrombosis Cerebral aneurysm Small artery thrombosis
Cerebral aneurysm
The nurse is caring for a client who underwent surgery to remove a spinal cord tumor. When conducting the postoperative assessment, the nurse notes the presence of a bulge at the surgical site. The nurse suspects the client is experiencing what complication from the surgery? Infection at the surgical site Impaired tissue healing Cerebrospinal fluid leakage Growth of a secondary tumor
Cerebrospinal fluid leakage
The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? Crackles auscultated bilaterally Oral temperature of 97°F Respiratory rate of 10 breaths/minute Pain and tenderness in calf area
Crackles auscultated bilaterally
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first? Administer prescribed antibiotics. Apply a cooling blanket. Initiate isolation precautions. Ensure the family receives prophylaxis antibiotic treatment.
Initiate isolation precautions.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? Surgery 6 weeks ago Two hour time period of the stroke Taking digoxin International normalized ratio greater than 2
International normalized ratio greater than 2
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Hydrochloric acid Liver enzyme Histamine Intrinsic factor
Intrinsic factor
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Nebulizer and thermometer Blood pressure apparatus Intubation tray and suction apparatus Incentive spirometer
Intubation tray and suction apparatus
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Lateral, with right leg flexed Lateral recumbent, with thighs flexed Prone, with the head turned to the right Supine, with the knees raised toward the chest
Lateral recumbent, with thighs flexed
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Altered intellectual ability Slow, cautious behavior Left visual field deficit Aphasia
Left visual field deficit
Bone density testing will be completed for the client with post-polio syndrome. The nurse teaches the client bone density testing is used to identify what potential complication? Calcification of long bones Osteoarthritis Pathologic fractures Low bone mass and osteoporosis
Low bone mass and osteoporosis
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? Evaluation of nutritional status and metabolic state Lung auscultation and measurement of vital capacity and tidal volume Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort
Lung auscultation and measurement of vital capacity and tidal volume
Which of the following is accurate regarding a hemorrhagic stroke? It is caused by a large-artery thrombosis. Functional recovery usually plateaus at 6 months. Main presenting symptom is an "exploding headache." One of the main presenting symptoms is numbness or weakness of the face.
Main presenting symptom is an "exploding headache."
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. Symptoms will evolve over a period of 1 week. Bleeding continues into the intracerebral area. The crash cart with defibrillator is kept nearby.
Monitoring is needed as rapid neurologic deterioration may occur.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Monro-Kellie Dawn phenomenon Hashimoto's disease Cushing's
Monro-Kellie
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? 100 to 150 mL/h More than 200 mL/h 150 to 200 mL/h 50 to 100 mL/h
More than 200 mL/h
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? Hemolytic anemia Multiple myeloma Polycythemia vera Leukemia
Multiple myeloma
Clients with multiple myeloma have abnormal plasma cells that proliferate in the bone marrow where they release osteoclast-activating factor, resulting in the formation of osteoclasts. What is the most common complication of the pathology resulting from this process? Calcified bones Increased mobility Pathologic fractures Osteoporosis
Pathologic fractures
Which is a symptom of severe thrombocytopenia? Inflammation of the tongue Inflammation of the mouth Dyspnea Petechiae
Petechiae
A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client? Sternum Ankle Femur Posterior iliac crest
Posterior iliac crest
A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure? Trendelenburg Supine Knee-chest Prone
Prone
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): Extension of the esophagus through an opening in the diaphragm. Protrusion of the upper stomach into the lower portion of the thorax. Involution of the esophagus, which causes a severe stricture. Twisting of the duodenum through an opening in the diaphragm.
Protrusion of the upper stomach into the lower portion of the thorax.
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Dementia Slow, shuffling gait Rapid, jerky, involuntary movements Dysphagia and dysphonia
Rapid, jerky, involuntary movements
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Rapid, jerky, involuntary movements Slow, shuffling gait Dementia Dysphagia and dysphonia
Rapid, jerky, involuntary movements
A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following? Bowel incontinence Respiratory dysfunction Skin breakdown Hemorrhage
Respiratory dysfunction
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Maintaining adequate hydration Restricting fluid intake and hydration Administering prescribed antipyretics Hyperoxygenation before and after tracheal suctioning
Restricting fluid intake and hydration
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? Hypertension and narrowing pulse pressure Hypotension and tachycardia Rising blood pressure and bradycardia Hypotension and bradycardia
Rising blood pressure and bradycardia
A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times? Supine with a small pillow under the patient's head Side-lying with the head slightly lower than the chest High Fowler's with the patient sitting erect Semi-Fowler's with the head of the bed elevated 30 to 45 degrees
Semi-Fowler's with the head of the bed elevated 30 to 45 degrees
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A complete blood count including differential A sigmoidoscopy Gastric analysis Serum antibodies for H. pylori
Serum antibodies for H. pylori
After a seizure, the nurse should place the patient in which of the following positions to prevent complications? High Fowler's, to prevent aspiration Side-lying, to facilitate drainage of oral secretions Semi-Fowler's, to promote breathing Supine, to rest the muscles of the extremities
Side-lying, to facilitate drainage of oral secretions
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? Large Intestine Ileum Liver Stomach
Stomach
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Take daily weights. Assess for pupillary response frequently. Assess vital signs frequently. Reposition the client frequently.
Take daily weights.
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge? Pant like a dog Take long, slow breaths Bear down as if having a bowel movement Hold his breath
Take long, slow breaths
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has an elevated temperature. The client has cerebral spinal fluid (CSF) leaking from the ear. The client has serous drainage from the nose. The client has ecchymosis in the periorbital region.
The client has cerebral spinal fluid (CSF) leaking from the ear.
Which client should the nurse assess for degenerative neurologic symptoms? The client with Paget disease. The client with glioma. The client with Huntington disease. The client with osteomyelitis.
The client with Huntington disease.
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? Bell's palsy Migraine headache Trigeminal neuralgia Angina pectoris
Trigeminal neuralgia
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Apply supplemental oxygen to maintain the client's oxygenation. Use an electric razor when assisting client with shaving. Where a mask when entering the client's room. Elevate the client's head of the bed.
Use an electric razor when assisting client with shaving.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: Kernig's sign. Brudzinski's sign. a positive edrophonium (Tensilon) test. a positive sweat chloride test.
a positive edrophonium (Tensilon) test.
The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron? C D E A
c
When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as decerebrate. decorticate. normal. flaccid.
decerebrate.
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: decrease the potential for brain damage. assess for infection. prevent embolism. follow hospital protocol.
decrease the potential for brain damage.
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? constipation, dehydration, and hypercapnia. manifestations of hypoglycemia. diaphoresis, vomiting, and diarrhea. manifestations of electrolyte disturbances.
diaphoresis, vomiting, and diarrhea.
A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke? problems with abstract thinking, impairment of short-term memory, poor judgment expressive aphasia, defects in the right visual fields, problems with abstract thinking cautious behavior, deficits in left visual fields, misjudgment of distances impulsive behavior, poor judgment, deficits in left visual fields
impulsive behavior, poor judgment, deficits in left visual fields
Which condition is caused by improper catheter placement and inadvertent puncture of the pleura? pneumothorax fluid overload air embolism sepsis
pneumothorax
The most significant complication related to continuous tube feedings is the potential risk for aspiration. interruption of GI integrity. disturbance in the sequence of intestinal and hepatic metabolism. interruption in fat metabolism and lipoprotein synthesis.
potential risk for aspiration.
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: promote carbon dioxide elimination. lower arterial pH. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. prevent respiratory alkalosis.
promote carbon dioxide elimination.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the supine position with the head slightly elevated. prone position with the head turned to the unaffected side. Trendelenburg position. dorsal recumbent position.
supine position with the head slightly elevated.
Bell palsy is a disorder of which cranial nerve? Vagus (X) Facial (VII) Trigeminal (V) Vestibulocochlear (VIII)
Facial (VII)
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Form words that are understandable or comprehend spoken words Speak at all Comprehend spoken words Form words that are understandable
Form words that are understandable or comprehend spoken words
A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? Frontal lobe Temporal lobe Occipital lobe Parietal lobe
Frontal lobe
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Gastroesophageal reflux disease Esophageal cancer Diverticulitis Peptic ulcer disease
Gastroesophageal reflux disease
Which blood cell type is matched correctly with its function? B lymphocyte: Secretes immunoglobulin Plasma cell: Cell-mediated immunity Leukocyte: Fights infection T lymphocyte: Humoral immunity
Leukocyte: Fights infection
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Mannitol Half-normal saline (0.45% NSS) Dextrose 5% in water (D5W) One-third normal saline (0.33% NSS)
Mannitol
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: electromyography (EMG). Doppler scanning. quantitative spectral phonoangiography. Doppler ultrasonography.
electromyography (EMG).
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? chewing smelling swallowing tasting
chewing
Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? Seizures Restlessness Change in level of consciousness (LOC) Pupil changes
Change in level of consciousness (LOC)
A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? Coffee Toast Orange juice Eggs
Coffee
A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Computer tomography Small bowel series Colonoscopy Upper GI series
Colonoscopy
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements? Immune globulin is given intravenously. The thymus gland is removed. Antibodies are removed from the plasma. Mestinon therapy is initiated.
Antibodies are removed from the plasma.
Which is a late sign of increased intracranial pressure (ICP)? Headache Irritability Slow speech Altered respiratory patterns
Altered respiratory patterns
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Neutrophil Plasma cell B lymphocyte Basophils
Basophils
Which of the following is the most definitive means of assessing for liver disease? Ultrasonography Paracentesis Cholecystography Biopsy
Biopsy
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? Seizures Depression Myasthenia gravis Parkinson's disease
Depression
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Loss of proprioception Patchy blindness Numbness Diplopia and ptosis
Diplopia and ptosis
The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? Elevation of the extremity Pressure point control Application of a tourniquet Direct pressure
Direct pressure
A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following? Micrographia Dysphonia Bradykinesia Dyskinesia
Dyskinesia
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Begin an infusion of normal saline in another site to maintain hydration. Slow the current infusion rate so that it will last until the new solution arrives. Hang a solution of dextrose 10% and water until the new solution is available. Have someone go to the pharmacy to obtain the new solution.
Hang a solution of dextrose 10% and water until the new solution is available.
The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following? Pancreatitis Diabetes insipidus Kidney failure Heart failure
Heart failure
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Methyldopa Heparin sodium Phenytoin Dexamethasone
Heparin sodium
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Infection Exacerbation of uncontrolled hypertension Increase in cerebral perfusion pressure Increased ICP
Increased ICP
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Systolic blood pressure less than or equal to 185 mm Hg Age 18 years or older
Intracranial hemorrhage
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Lymphoid stem cell Neutrophil Myeloid stem cell Monocyte
Myeloid stem cell
A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? Insufficient intake of dietary nutrients Neurologic involvement Severity of the disease Loss of vibratory and position senses
Neurologic involvement
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? Endocrine system Neurovascular system Respiratory system Cardiovascular system
Neurovascular system
A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? Pancytopenia Neutropenia Thrombocytopenia Anemia
Neutropenia
Which is the initial diagnostic test for a stroke? Noncontrast computed tomography Transcranial Doppler studies Electrocardiography Carotid Doppler
Noncontrast computed tomography
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma: Metastasized from a cancer in another part of the body. Developed on the cranial nerves. Originated within the brain tissue. Originated from the coverings of the brain.
Originated within the brain tissue.
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? Osteopathic tumors destroy bone causing fractures. Osteolytic activating factor weakens bones producing fractures. Osteosarcomas form producing pathologic fractures. Osteoclasts break down bone cells so pathologic fractures occur.
Osteoclasts break down bone cells so pathologic fractures occur.
The most common cause of cholinergic crisis includes which of the following? Infection Undermedication Overmedication Compliance with medication
Overmedication
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Balancing rest and activity Monitoring respiratory status Preventing bone injury Restricting fluid intake
Preventing bone injury
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Severe headache and early change in level of consciousness Weakness on one side of the body and difficulty with speech Confusion or change in mental status Foot drop and external hip rotation
Severe headache and early change in level of consciousness
Which type of hemolytic anemia is categorized as inherited disorder? Cold agglutinin disease Hypersplenism Autoimmune hemolytic anemia Sickle cell anemia
Sickle cell anemia
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Extradural hematoma Subdural hematoma Intracerebral hemorrhage Epidural hematoma
Subdural hematoma
The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client? Magnetic resonance imaging Computed tomography Cerebral angiography Transcranial Doppler
Transcranial Doppler
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Transient ischemic attack Left-sided stroke Cerebral aneurysm Right-sided stroke
Transient ischemic attack
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? Anxiety or irritability Hyperactivity Uncontrolled rhythmic movements of the face or limbs Dry mouth not relieved by sugar-free hard candy
Uncontrolled rhythmic movements of the face or limbs
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client? Vascular occlusion in small vessels decreasing blood and oxygen to the tissues. The client has a decreased tolerance of pain related to the chronic nature of the illness. Bone marrow decreases the erythrocyte production causing decrease in hypoxia. Overhydration enlarges the red blood cells.
Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? Hypertonic saline solution Diet containing extra sodium Fluid restriction Vasopressin therapy
Vasopressin therapy
An client has pernicious anemia and has been receiving treatment for several years. What is the client lacking that results in pernicious anemia? extrinsic factor intrinsic factor vitamin B hemoglobin
intrinsic factor
A nurse is working on a surgical floor. The nurse must logroll a client following a: thoracotomy. laminectomy. cystectomy. hemorrhoidectomy.
laminectomy
A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response? stomach small intestine rectum large intestine
large intestine
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? metoclopramide a low-fat diet elevation of upper body on pillows pantoprazole
metoclopramide
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has? Too many erythrocytes A general reduction in neutrophils and basophils A decrease in granulocytes A general reduction in all white blood cells
A general reduction in all white blood cells
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? A hemolytic reaction to mismatched blood A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic reaction to Rh-incompatible blood
A hemolytic allergic reaction caused by an antigen reaction
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Neutropenia Anemia Thrombocytopenia Leukopenia
Thrombocytopenia
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? "Who is the president of the United States?" "Can you write your name on this piece of paper?" "Are you having hallucinations now?" "Can you count backward from 100?"
"Who is the president of the United States?"
Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? A 24-year-old female taking oral contraceptives A 40-year-old patient with a history of hypertension A 72-year-old patient with a history of cancer A 52-year-old patient with acute kidney injury
A 72-year-old patient with a history of cancer
The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents? Administer over-the-counter preparations for a cold Administer factor VIII intravenously at the first sign of bleeding Encourage the toddler to participate in playground activities with other toddlers Use nasal packing for any nose bleeds
Administer factor VIII intravenously at the first sign of bleeding
The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption? Myelodysplastic syndrome Thrombocytopenia Anemia Neutropenia
Anemia
Which of the following is the most common hematologic condition affecting elderly patients Thrombocytopenia Leukopenia Bandemia Anemia
Anemia
A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Ask if taking a blood pressure has ever produced pain in the upper arm. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. Ask if taking a blood pressure has ever produced the need for medication.
Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Maintain the client NPO for 6 hours before the test. Obtain a blood sample to evaluate BUN and creatinine concentrations. Obtain two large-bore IV lines. Assess the client for medication allergies.
Assess the client for medication allergies.
A client with AML has pale mucous membranes and bruises on the legs. What is the primarynursing intervention? Assess the client's skin. Check the client's history. Assess the client's hemoglobin and platelets. Assess the client's pulse and blood pressure.
Assess the client's hemoglobin and platelets.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions? Encouraging early and frequent activities. Keeping long activity periods to build client stamina. Assisting in prioritizing activities. Determining what days to be active.
Assisting in prioritizing activities.
Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? Spasticity Ataxia Rigidity Agnosia
Ataxia
The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency? Folate A B12 C
B12
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Severe thrombocytopenia Gradual muscle paralysis Bone pain in the back of the ribs Debilitating fatigue
Bone pain in the back of the ribs
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Potassium level of 5.2 mEq/L Creatinine level of 6 mg/100 mL Calcium level of 9.4 mg/dL Magnesium level of 2.5 mg/dL
Creatinine level of 6 mg/100 mL
During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take? Observe for additional symptoms and notify the physician Discontinue the infusion immediately and notify the physician Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Slow the infusion rate and continue to monitor the client every 15 minutes
Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? Encourage the client to drink liberal amounts of fluids Keep the room brightly lit and play soothing music in the background Help the client take a brisk walk around the testing area Administer antihistamines according to the physician's prescription
Encourage the client to drink liberal amounts of fluids
A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Provide the client with a list of the nearest donation centers. Tell the client that 2 units of blood will be needed.
Explain the time frame needed for autologous donation.
Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? Vestibulocochlear Facial Oculomotor Trigeminal
Facial
When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Lifestyle assessments, such as exercise routines Age and gender Menstrual history
Health history, such as bleeding, fatigue, or fainting
A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Folate levels Creatinine level Potassium level Hemoglobin level
Hemoglobin level
A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? Shock Splintering of bone fragments Hemorrhage Blood transfusion reaction
Hemorrhage
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is mostappropriate for this client? Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Fatigue related to decreased hemoglobin and hematocrit Risk for falls related to complaints of dizziness Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have? Iron deficiency anemia Sickle cell anemia Aplastic anemia Megaloblastic anemia
Iron deficiency anemia
A nurse caring for a client with myeloma prepares to administer dexamethasone to the client. What is the nurse's best understanding of how this medication is an effective treatment option for this client? It decreases immune response. It decreases tumor necrosis factor. It kills affected cells. It kills affected bone marrow.
It kills affected cells.
The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It is part of the required assessment information. It may indicate deficiencies in essential nutrients. It is important for the nurse to determine what type of foods the patient will eat. It will determine what type of anemia the patient has.
It may indicate deficiencies in essential nutrients.
The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? Strong pedal pulses Absence of tenting skin turgor White sclera Jugular venous distention
Jugular venous distention
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Supine with head of the bed elevated 30 degrees Lateral position with one leg flexed Jackknife position Lithotomy position
Lateral position with one leg flexed
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Chronic myeloid leukemia Non-Hodgkin lymphoma Hodgkin lymphoma Multiple myeloma
Multiple myeloma
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Hodgkin lymphoma Chronic myeloid leukemia Multiple myeloma Non-Hodgkin lymphoma
Multiple myeloma
What assessment finding best indicates that the client has recovered from induction therapy? No evidence of edema Absence of bone pain Vital signs within normal ranges Neutrophil and platelet counts within normal limits
Neutrophil and platelet counts within normal limits
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Anemia Pancytopenia Leukopenia Thrombocytopenia
Pancytopenia
The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? Central Peripheral Parasympathetic Sympathetic
Parasympathetic
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? Teach the client to vigorously floss the teeth to prevent infections. Request a prescription of diphenoxylate and atropine for loose stools. Perform a neurologic assessment with vital signs. Use contact precautions with this client.
Perform a neurologic assessment with vital signs.
A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Place the client in a recumbent position with legs elevated. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent. Remove the intravenous line.
Remain for observation after eating and drinking.
A client has hereditary hemochromatosis. Laboratory test results indicate an elevated serum iron level, high transferrin saturation, and normal complete blood count (CBC). What is most important action for the nurse to take? Inform the client to limit ingestion of alcohol. Educate about precautions to follow after a liver biopsy. Remove the prescribed one unit of blood. Instruct the client to limit iron intake in the diet.
Remove the prescribed one unit of blood.
The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? Received a blood transfusion within 1 year Had a dental extraction 2 days ago for caries in a tooth Reports having a cold 1 month ago that resolved quickly Has a history of viral hepatitis as a teenager 10 years ago
Reports having a cold 1 month ago that resolved quickly
Which type of lymphocyte is responsible for cellular immunity? Basophil T lymphocyte Plasma cell B lymphocyte
T lymphocyte
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Avoid contact with family/friends who are sick. Encourage frequent handwashing. Plan for frequent periods of rest. Use a disposable razor when shaving.
Use a disposable razor when shaving.
The client is to receive a unit of packed red blood cells. What is the nurse's first action? Verify that the client has signed a written consent form. Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells.
Verify that the client has signed a written consent form.
A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem? Folic acid deficiency Vitamin C deficiency Vitamin A deficiency Vitamin B12 deficiency
Vitamin B12 deficiency
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? Vitamin A Vitamin K Vitamin D Vitamin E
Vitamin K
A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: close his or her eyes and discriminate between dull and sharp. close his or her eyes and jump on one foot. touch his or her nose with one finger. close his or her eyes and stand erect.
close his or her eyes and stand erect.
The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide: used mild soapy water to clean the face. cleaned the neck and upper chest area. moved the client's head to clean behind the ears. cleaned the eye area from the inner to outer eye area.
moved the client's head to clean behind the ears.
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Reposition the client to a high Fowler position and continue to monitor the pain Administer acetaminophen 500 mg po, as ordered Administer aspirin (ASA) 325 mg po, as ordered Notify the physician
Administer acetaminophen 500 mg po, as ordered
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. This type of exercise increases arterial circulation as it returns to the heart. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? Take an iron supplement with meals to reduce gastric irritation. Decrease the intake of citrus fruits because they interfere with iron absorption. Increase the intake of green, leafy vegetables. Decrease the intake of high-fat red meats, especially organ meats.
Increase the intake of green, leafy vegetables.
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Elevated red blood cell (RBC) count Enlarged mean corpuscular volume (MCV) Elevated hematocrit concentration Low ferritin level concentration
Low ferritin level concentration
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation? Sit up promptly after the needle is removed. Hold the involved arm below the heart. Remain for observation after eating and drinking. Remove the band-aid after 5 minutes.
Remain for observation after eating and drinking.
A client with chronic anemia has received multiple transfusions. Which client action would the nurse be concerned about relative to the client's condition? Takes a daily multiple vitamin pill Takes over-the-counter iron supplements Eliminates use of alcohol Takes 60 grams of protein each day
Takes over-the-counter iron supplements
The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma? The client with enlarged lymph nodes in the neck. The client with painful lymph nodes under the arm. The client with painful lymph nodes in the groin. The client with a painful sore throat.
The client with enlarged lymph nodes in the neck.
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The brain senses low oxygen levels in the blood and produces hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. The kidneys sense low oxygen levels in the blood and produce hemoglobin, stimulating the marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood to produce erythropoietin, maturing the red blood cells.
The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells.
