AH 3 Exam 2 practice
The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
"I empty the urinary collection bad when it is two-thirds full." Should be at 1/3 fullness so it doesn't stretch and leak.
The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? SATA
"I need to take a hot bath every evening." "I need to rest for long periods of time every day."
Acetylsalicylic acid has been prescribed for client with rheumatoid arthritis, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?
"I need to take this medication on an empty stomach for it to work."
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?
"I should take hot baths because they are relaxing."
The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? SATA
- Ask permission before touching the client. - Eliminate all unnecessary physical contact with the client. - Defuse any anger or verbal attacks with a nondefensive stance. - Use simple and clear language when communicating with the client.
A client is taking large doses of acetylsalicylic acid for rheumatoid arthritis. Which assessment findings indicate that the client is experiencing ototoxicity as a result of the medication?
Tinnitus, hearing loss, dizziness, and ataxia
Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide?
Drink 3000 mL of fluid a day.
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency?
Electrocardiographic changes hypercalcemia makes for bad heart rhythms
The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? SATA
Fatigue Morning stiffness
An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client?
Risk for self-harm
The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
The passage of flatus.
A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate?
The presence of unusual antibodies of the IgG and IgM types.
A client is receiving a new prescription for colchicine. Which information about this medication should the nurse include in an educational session?
This is an anti-inflammatory agent specific for gout.
The nurse receives a call from client taking immunotherapy drugs for cancer treatment. The client reports fever, chills, diarrhea, and general malaise. The nurse advises the client to take which action?
This one i think is either "Take acetaminophen as prescribed." or "Immediately alert the healthcare provider of the client's condition." but i am unsure and could not find anything on google
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?
Abdominal distention I think this means the cancer has metastasized
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
Protecting the client from infection.
The nurse cares for a client beginning radiation therapy for uterine cancer treatment. Which statement does the nurse include when teaching the client about skin care during radiation therapy?
"Avoid wearing belts or pants with an elastic waistband."
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?
"Do you feel afraid that people are trying to hurt you?"
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicyl acid. The nurse determines that the client needs additional teaching if the client makes which statement?
"I need to continue to take the aspirin until the day of surgery"
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."
"I'm going to take aspirin for my headache as soon as I get home." Aspirin is blood thinner
A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response?
"It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."
The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction?
"Pain or fatigue is expected, and I should try to continue the activity if this occurs"
A film-coated form of diflunisal, a nonsteroidal anti-inflammatory medication, has been prescribed for a client to treat chronic rheumatoid arthritis. The client calls the clinic nurse because of the difficulty swallowing the tablets. Which instruction should the nurse provide to the client?
"Swallow the tablets with large amounts of water or milk."
Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?
"This medication can be taken to prevent and treat clients with breast cancer."
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
"When I have command hallucinations, I'll call a friend for help."
A client with gout has begun to take allopurinol. The nurse informs the client that which medication may also be necessary during the beginning phase of medication therapy with allopurinol? SATA
Naproxen Colchicine Indomethacin
The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?
One week after menstruation begins.
A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse should check to see that the client takes the medication at what time?
30 minutes before meals
The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
A platelet count of 50,000 mm^3 (50 x 10^9)/L
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
A structured program of activities in which the client can participate
A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis?
A temporary worsening of the condition
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
Age younger than 50 years. Family history of colorectal cancer, personal history of colorectal polyps, and current chronic inflammatory bowel disease are all risk factors for CRC.
The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA?
Anorexia
The nurse who is caring for a client with myasthenia gravis has a prescription to perform an edrophonium test. After obtaining edrophonium the nurse should be certain that which is also available at the bedside?
Atropine sulfate
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought process. In formulating a nursing plan of care, which best intervention should the nurse include?
Avoid using a whisper voice in front of the client
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
Avoidant
The home health nurse is providing dietary instructions to a client who is taking probenecid for the treatment of gout. Which food should the nurse instruct the client to continue to eat?
Spinach
The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in client?
Uric acid level of 9.0 mg/dL (0.54 mmol/L)
The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? SATA
Chew food thoroughly. Cut food into very small pieces. Sit straight up in the chair while eating. Swallow when the chin is tipped slightly downward to the chest
A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food?
Chicken liver
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SATA
Communicate expected behaviors to the client Assist the client in identifying ways of setting limits on personal behaviors Follow through about the consequences of behavior in a nonpunitive manner Have the client state the consequences for behaving in ways that are viewed as unacceptable
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?
Continue to monitor the drainage. right after surgery (postoperative period), bleeding is normal
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
Conversion disorder
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test?
Decreased numbers of all cell types.
The nurse is caring for a client who just underwent a left mastectomy. The nurse should plan to place the left arm in which position?
Elevated on a pillow.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
Elevating the affected arm on a pillow above heart level.
The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
Encouraging fluids. this dilutes the serum calcium
A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?
Enlarged lymph nodes
The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?
Increased calcium level
The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A high sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP?
Erythrocyte sedimentation rate (ESR)
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
Escort the client to their room, with the assistance of other staff
The nurse is caring for a client with lung/bladder cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? SATA
Facial edema in the morning, Serum calcium level of 12 mg/dl, numbness and tingling of the lower extremities.
The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE?
Facial rash
The nurse is reviewing the health care record of a client with new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? SATA
Fatigue Anorexia Generalized weakness
The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement?
Going to the beach will be a nice, relaxing form of activity.
The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?
Hematuria
The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching?
I can change the time of my medication on the mornings when I feel strong.
A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?
I hear what you are saying, but I don't share your belief.
Probenecid has been prescribed for a client with a diagnosis of gout, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction?
I should take acetylsalicylic acid for relief of headache.
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?
Identifying anxiety-producing situations
The primary health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? SATA
If symptoms worsen following administration of edrophonium, the crisis is cholinergic. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. An improvement in symptoms following administration of edrophonium indicates worsening of myasthenia gravis.
The nurse assesses a client with borderline personality disorder. Which assessment does the nurse expect to see?
Impulsive and reckless behavior, inappropriate and intense anger
Allopurinol has been prescribed for a client with a diagnosis of gout. The nurse develops a list of instructions for the client regarding the use of this medication. Which measures should be included on the list? SATA
Increase fluid intake. Take the medication with food. Consume items to maintain an alkaline urine. Return to the health care clinic for liver and renal function tests.
A week after kidney transplantation, a client develops a temperature of 101 F (38.3 C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?
Increased immunosuppression therapy
A client has been taking glucocorticoids to control rheumatoid arthritis. Which laboratory abnormality is the client at risk for as a result of taking this medication?
Increased serum glucose
The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?
Increased uric acid level
The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response should the nurse make to the client?
It will last for about 4 to 5 minutes.
The home health nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse evaluates that the medication is effective if the client reports a decrease in which measure?
Joint inflammation
The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? SATA
Joint pain that diminishes after rest. Joint pain that intensifies with activity
When caring for a client with an internal radiation implant, the nurse should observe which principles? SATA
Keep pregnant women out of the client's room, place client in a private room with a private bath, wearing a lead shield when providing direct client care
A client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation?
Making decisions about living arrangements after discharge
The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?
Malnutrition
Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?
Measure the client's current weight and height.
Chemotherapy dosage is frequently based on total body surface area, so it is important for the nurse to perform which assessment before administering chemotherapy?
Measure the client's current weight and height.
A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention?
Monitor the chest tube drainage
A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner?
On time
The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note?
Pathological fracture, urinalysis positive for nitrites/Bence Jones protein, Serum creatinine level of 2.0 mg/dL
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit.
A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? SATA
Radiation, Chemotherapy, Serum sodium level determination, Medication that is antagonistic to antidiuretic hormone
The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action?
Restricting fluids
Which tests can be used to diagnose gout? Select all that apply.
Serum uric acid level, 24 hour urine uric acid level, synovial fluid aspiration
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?
Setting limits on the client's behavior
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in fetal position. Which is the most appropriate nursing intervention?
Sit beside the client in silence and verbalize occasional open-ended questions.
A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis?
Skin biopsy
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE?
Skin lesions
In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? SATA
Symptom control during periods of emotional stress Normal white blood cell, platelet, and neutrophil counts. Radiological findings that show no progression of joint degeneration An increased range of motion in the affected joints 3 months into therapy
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?
The client's pain rating
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
The development of a vesicovaginal fistula.
During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breach of boundaries?
The focus of today's session is on your issues, so lets get started.
The primary health care provider has prescribed a lidocaine 5% patch for a client with a diagnosis of neck pain due to osteoarthritis. Which should the nurse tell the client regarding this medication?
The medication patch will act as a local anesthetic.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
Use an indirect light source and turn off the television
A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?
WBC count and platelet count
A client newly diagnosed with gout has been prescribed allopurinol. The nurse would be concerned if the client was also currently taking which medication?
Warfarin
Diclofenac is prescribed for a client with osteoarthritis. Which medication, if noted on the client's record, would alert the nurse to consult with the primary health care provider?
Warfarin sodium
The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? SATA
1. Stop the infusion. 2. Notify the health care provider (HCP). 3. Prepare to apply ice or heat to the site. 5. Prepare to administer a prescribed antidote into the site.
A client is diagnosed as having an intestinal/bowel tumor. The nurse should monitor the client for which complications of this type of tumor? SATA
Peritonitis, Hemorrhage, Fistula formation, Bowel perforation
A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside?
Ambu bag and suction equipment
The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. Evaluation of the results indicates that the test is positive. Which would be the expected response noted by the nurse?
An increase in muscle strength within 1 to 3 minutes.
A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis?
An increase in muscle strength within 30 to 60 seconds following administration of the medication
Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery?
Arm edema on the operative side
The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?
Bowel sounds Pelvic exenteration is removal of the organs in the pelvic cavity
The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?
Periorbital edema
A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder?
Systemic lupus erythematosus (SLE)
The nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. Which immune order should the nurse primarily anticipate?
Systemic lupus erythematosus (SLE)
The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA?
Systemic symptoms such as fatigue, anorexia, and weight loss
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?
Taking medications as scheduled.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
Teach client and family about the need for hand hygiene.
A client with cancer pain is prescribed oxycodone/hydrocodone. Which teaching is most essential to help prevent long-term complications?
Teach the client how to prevent constipation.
The nurse cares for a client with chemotherapy-induced neutropenia. The nurse intervenes after observing which action by the unlicensed assistive personnel (UAP)?
The UAP permits the client to rest instead of performing evening oral care.
The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?
The best time to fondle your balls is after a shower
A client with muscle aches and diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse determines that the client understands the use of the medication if the client makes which statement?
The medication will act as a local analgesic.
An older client with rheumatoid arthritis has been instructed by the primary health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which?
The normal adult dose
A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The primary health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication in available in the event that the client is in cholinergic crisis?
again, Atropine sulfate
