EAQ UNIT 3
which client statement indicates a risk of breast cancer?
My first child was born when i was 32 I noticed a slight discharge from a nipple i consume two to four glasses of alcohol a day
during a physical examination, which assessment would the nurses anticipate when a client is placed in the lithotomy position
female genitalia
which metabolic manifestations are likely to be observed in a client with hypothyroidism?
intolerance to cold decreased body temperature
which data collection assessment would be performed to evaluate the effectiveness of furosemide administered to a client with congestive heart failure?
- daily weight - intake and output - monitor for edema - daily pulse oximetry - auscultate breath sounds
A client experiencing thyrotoxic crisis tells the nurse "I know I'm going to die. I am very sick" which is the best response by the nurse?
You must feel very sick and frightened
which finding is more likely to indicate a malignancy in a 38 year old client admitted for a biopsy of a breast lump?
a lesion in the upper outer quadrant that is poorly delineated and immobile
while assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?
bruit
which structure is included in the external genitalia of the male anatomy?
penis scrotum
which action would the nurse take next when a client with a history of heart failure on daily weights has a 4 pound weigh gain since the previous day?
perform a head to toe assessment - performing head to toe assessment including vital signs would indicate symptoms, such as jugular distention with right sided heart failure, or pulmonary crackles associated with left sided heart failure.
which structure is removed during circumcision?
prepuce
which client is most at risk for osteoporosis?
-A 66-year-old white woman, 5 foot 1 inch and 100 lb, who is a paralegal A postmenopausal woman who is small-boned, thin, and relatively sedentary is at risk for osteoporosis; other risk factors are family history, and white or Asian ethnicity. The postmenopausal years are considered to be 65 years and older; however, each individual is unique. A perimenopausal woman who is relatively heavy and does not smoke is at less risk for osteoporosis than is a thin postmenopausal woman. The perimenopausal years are considered to be 45 to 64 years of age; however, each individual is unique. Postmenopausal women who are black are at lower risk for osteoporosis than are white and Asian women. A perimenopausal woman who takes a daily calcium supplement is at less risk for osteoporosis than a woman who does not take a calcium supplement.
which position would the nurse place the feet and legs in when caring for a client with peripheral arterial insufficiency?
place them slightly lower than the head and the chest. - gravity will assist the flow of blood to the dependent legs and feet (placed lower than the head and chest)
which position should a patient lay during an assessment of their heart
the client should lie in the lateral recumbent position so he nurse may effectively detect heart murmurs
the nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements?
-i should drink at least six glasses of water every day - i can include bran muffins in my breakfast daily - i will walk every day as part of my exercise regimen
which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints
inflammation in the joint's synovial lining in rheumatoid arthritis, transformed autoantibodies attack synovium, producing inflammation.
a client who had subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. which would the nurse consider when formulating a response?
less thyroid tissue is available to supply thyroid hormone after surgery - after a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate.
while auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. which client has the highest risk for heart failure?
older adult client - the S3 is the third heart sound heard after the normal "lub-dub". It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 years old clients, the third heart sound is often considered to be a normal parameter.
which findings in a client may indicate potential thyrotoxic crisis
rapid heartbeat and tremors - refers to a sudden and excessive release of thyroid hormones, which causes pyrexia and tachycardia
one week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and fever. the client is admitted with a diagnosis of thyrotoxic crisis. which intervention is appropriate to implement for this client?
reduce body temperature and heartrate - immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. the need is for an increase, not decrease, in fluid intake to compensate for that loss because of the high metabolic rate.
ulnar drift
results in ulnar deviation of the fingers at the MCP joints - occurs when the long axis of the fingers makes an angle with the long axis of the wrist so that the fingers are deviated to the ulnar side of the hand.
the nurse assess bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
shift of fluid into the interstitial spaces - edema is defined as the accumulation of fluid in the interstitial spaces. when the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces.
when taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?
using several pillows to sleep at night - heart failure causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down.
which manifestation would the nurse expect to find when assessing a client with hyperthyroidism?
weight loss tachycardia restlessness exophthalmos
a client is admitted for a biopsy of a tumor in her left breast. the client states "i know it cant be cancer, because it doesn't hurt" which response by the nurse is most therapeutic?
what do you know about breast cancer? - asking what the client knows about breast cancer allows the nurse to assess the client's understanding of breast cancer and to clarify any misconceptions.
an older adult male client asks about the risks of having osteoporosis. which response would the nurse make
you might consider having a bone density test
to assess the status of circulation to the foot, which site would the nurse monitor for a pulse?
- dorsalis pedis - posterior tibial
which time of the month would the nurse teach premenopausal women to perform breast self-examination
about a week after menses ends, breast engorgement has abated, limiting lumps that may occur because of fluid accumulation.
which assessment finding will the nurse expect when caring for a client with peripheral arterial disease?
absence of hair on the toes reports of pain associated with exercising (intermittent claudication)
which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra?
benign prostatic hyperplasia (bph) - benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra
which condition can be identified in a client using Phalen's test
carpal tunnel syndrome
which instruction will the home health nurse give when teaching a client with arterial insufficiency of both lower extremities?
check pulses in legs regularly - altered quantity and quality of pulses are the earliest indications of increasingly limited circulation.
which factors contribute to development of osteoporosis in female clients
cigarette smoking familial predisposition inadequate intake of dietary calcium
which activity would the nurse expect to cause the most distress when assessing a client with heart failure for activity tolerance?
climbing a flight of stairs to the bathroom
which urine characteristic is consistent with a urinary tract infection
cloudy - cellular debris, white blood cells, bacteria, and pus can cause the urine to become cloudy
which food disorder is caused by continual pressure over bony prominences
corn - caused by continual pressure over bony prominences
the nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. In which way would the nurse document the edema?
dependent edema arounf the area of the feet and ankles often indicated right sided heart failure or venous insufficiency. the nurse would assess for pitting edema by pressing firmly for several seconds then releasing for any depression left on the skin. 4+ indicates 8 mm depression 1+ indicates 2 mm 2+ indicates 4 mm 3+ indicates 6 mm
which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine
dilute urine - tends to appear very pale-yellow in color. fark red or brown urine indicates hematuria, dark0amber color urine indicates concentrated urine. red color urine may indicate the presence of myoglobinuria
which assessment finding is consistent with a client diagnosis of right sided heart failure?
distended abdomen dependent edema decreased appetite right sided heart failure is associated with increased systemic venous pressures and venous congestion, as manifested by an enlarged liver with possible ascites, dependent edema, and anorexia.
which assessment finding would the nurse expect when a client is diagnosed with left-sided congestive heart failure?
dyspnea crackles frequent cough -increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles, and cough
which nursing intervention is correct for a client with venous insufficiency?
elevate the clients legs above the heart level - venous insufficiency occurs when vascular damage impeded the body's ability to move blood from the legs toward the heart. this causes blood to pool in the legs, where it can cause swelling' pain' and in some cases leaking fluid in the skin or ulcers
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.
encourage early mobility - in the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. this reduces venous stasis and the risk of thrombophlebitis.
which part of the client's body would the nurse assess to identify osteoporotic changes?
vertebral column - compression fractures of the vertebrae are the most common fractures in clients with osteoporosis; a gradual collapse of vertebrae may be asymptomatic and observed as kyphosis.
Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure?
weighing the client
which statement would the nurse use to respond to an older adult client who states "I walk 2 miles a day for exercise, but now that the weather is hot, i am worried about becoming dehydrated"
fluids should be increased if the urine becomes darker
which structure indicated in the figure is the primary reproductive organ of the female
ovary
which clinical manifestations exhibited by a client taking levothyroxine for hypothyroidism for 3 months would cause a nurse to suspect that a decrease in dosage is needed
tremors heat intolerance
the nurse is assessing a client for possible malabsorption syndrome. which stool assessment finding supports this diagnosis?
fat globules - undigested fat in the feces (steatorrhea) is associated with diseases of the intestinal mucosa or pancreatic enzyme deficiency
a client is diagnoses with hyperthyroidism and is treated with I-131. Before discharge the nurses teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms would be included in the teaching?
fatigue, dry skin, progressive weight gain
after teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections, which client statement indicates effective learning?
i will consult with my primary health care provider when there is a rash or ulcer on my genitalia
which outcome is likely if the nurse palpates a client's joints during an acute episode of rheumatoid arthritis
pain
which clinical manifestation would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease?
pain with exercising and thickening of the toenails - inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails
which individual's activities increase the risk of developing carpal tunnel syndrome?
software engineer - carpal tunnel syndrome is a painful condition of the hands and the fingers that is caused by repetitive movement of the fingers and hand that lead to compression of the medial nerve near the wrist