Elsevier: Chapters 20, 49, 50, 53, 54, 55, 39, 40, 47

Question 14 of 16 The nurse is teaching a group of clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle change does the nurse emphasize? (Select all that apply.) Select all that apply. A) "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." B) "Begin a weight-training program for building muscle mass." C) "Liquid dietary supplements can be substituted safely for solid food." D) "Engage in moderate physical activity for at least 30 minutes each day." E) "Foods eaten away from home tend to be higher in fat than foods made at home." F) "Eat a variety of foods, especially grain products, vegetables, and fruits."

A) "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." D) "Engage in moderate physical activity for at least 30 minutes each day." E) "Foods eaten away from home tend to be higher in fat than foods made at home." F) "Eat a variety of foods, especially grain products, vegetables, and fruits." Lifestyle changes the nurse emphasizes include consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat than foods prepared at home. A weight-training program for building muscle mass does not need to be included in a weight loss program. Muscle weighs more and tends to increase weight in people who weight-train. Liquid dietary supplements cannot safely be substituted for solid food while attempting to lose weight. These types of liquid diets should be carefully supervised by a health care provider with special education in weight management.

Question 5 of 18 The nurse is teaching a client about starting glatiramer acetate. Which statement by the client indicates a need for further teaching? A) "I need to take this drug before breakfast at least once a week while I have weakness." B) "If I get flulike symptoms, which is not very likely, I'll take ibuprofen or acetaminophen." C) "I will avoid crowds and people who have infections because I'll be immunosuppressed." D) "I will rotate the site of the injections to prevent skin reactions from the drug."

A) "I need to take this drug before breakfast at least once a week while I have weakness." Because this drug is given parenterally, there is no need to take it with or without food. All of the other client statements are accurate and demonstrates client understanding.

Question 3 of 18 A client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for further teaching? A) "It's important I work out in the afternoon so my muscles are warmed up." B) "I can alternate wearing my eye patch between eyes for double vision." C) "I should keep my home clutter free so I don't fall." D) "I always keep my medications in the same place."

A) "It's important I work out in the afternoon so my muscles are warmed up." More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial. If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.

Question 14 of 14 The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious, and asks the nurse, "Does this mean I am going to die?". Which nursing response is appropriate? (Select all that apply.) A) "Let me sit with you for awhile and we can discuss how you are feeling about this." B) "You can beat this disease if you just put your mind to it." C) "No, surgery can cure you." D) "It sounds like death frightens you." E) "Let me call the hospital chaplain to talk with you."

A) "Let me sit with you for awhile and we can discuss how you are feeling about this." D) "It sounds like death frightens you." Acknowledging that death may frighten the client, and offering to talk about how the client is feeling, are therapeutic nursing interventions. Telling the client that surgery is curative, and promising the client can beat the disease, are nontherapeutic responses that provide false hope. Although talking with the chaplain at a later time may be requested by the client, the immediate need is to allow the client to express feelings to the nurse.

Question 10 of 20 The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A) "These interventions help to reduce the ammonia level." B) "These interventions help to prevent heart failure." C) "These interventions help the client's jaundice improve." D) "These interventions help to prevent nausea and vomiting."

A) "These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

Question 5 of 16 The nurse is performing a health assessment on a client with obesity who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? A) "What do you usually do that helps to relieve stress?" B) "What is it about your size that causes you to feel uncomfortable?" C) "Do you usually use alcohol or drugs when you feel stressed?" D) "Do you have a history of mental health concerns?"

A) "What do you usually do that helps to relieve stress?" The appropriate way to assess the client's response to stress is to ask an open-ended type of question because it cannot be answered with a "yes" or "no." From that answer, the nurse can better determine if the client eats in response to stress. Asking the client about mental health problems may cause the client to feel uncomfortable with the assessment and shut down. This subject can be more gently introduced later, if needed, based on the nurse's initial assessment. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about size will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.

Question 16 of 18 The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) A) "When lifting something, the back should be straight and the knees bent." B) "Do not wear high-heeled shoes." C) "Standing for long periods of time will help to prevent low back pain." D) "Begin a regular exercise program to strengthen your back." E) "Keep weight within 50% of ideal body weight."

A) "When lifting something, the back should be straight and the knees bent." B) "Do not wear high-heeled shoes." D) "Begin a regular exercise program to strengthen your back." The nurse includes the following instructions into the low back pain client's teaching plan: don't wear high-heeled shoes, begin a regular exercise program, and keep the back straight and knees bent when lifting something. Wearing high-heeled shoes can increase back strain. Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects and will help to prevent back injury. The client needs to avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight needs to be kept within 10% of ideal body weight and not 50%.

Question 11 of 16 An RN receives the change-of-shift report about these four clients. Which client will the nurse assess first? A) A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min B) A 50 year old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) C) A 30 year old admitted 2 hours ago with malnutrition associated with malabsorption syndrome D) A 45 year old who had gastric bypass surgery and is reporting severe incisional pain

A) A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min The nurse first assesses the client with dementia who has a respiratory rate of 38 breaths/min. This client needs immediate respiratory assessment and interventions. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. The client with malnutrition associated with malabsorption syndrome, the client with incisional pain from gastric bypass surgery, and the client receiving TPN with a BG of 300 mg/dL (16.7 mmol/L) all need assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority.

Question 21 of 22 The nurse is caring for a client who is diagnosed with middle stage (moderate) Alzheimer disease. What assessment findings would the nurse expect? (Select all that apply.) A) Agnosia B) Mild impaired cognition C) Sleeping problems D) Seizures E) Wandering F) Psychoses

A) Agnosia C) Sleeping problems D) Seizures E) Wandering F) Psychoses All of these choices except for mild impairment of cognition would be expected. The client with moderate AD has a more marked cognitive impairment.

Question 7 of 18 The nurse administered a prescribed dose of natalizumab for a client who is diagnosed with multiple sclerosis. For what adverse drug event will the nurse assess as the priority for this client within the first hour after administration? A) Anaphylactic or allergic reaction B) Elevation of liver enzymes C) Infection D) Neurologic changes such as confusion

A) Anaphylactic or allergic reaction While all of these adverse drug events are associated with natalizumab, the one that can occur within the first hour after administration is anaphylaxis. Infection can also cause fatality if it becomes systemic or the client develops progressive multifocal leukoencephalopathy (PML) which can cause mental and other neurologic changes.

Question 15 of 21 A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? A) Assess the level of the client's pain. B) Change the subject and talk about the client's hobbies. C) Distract the client with stories about the nurse's family. D) Remind the client that the lower leg was removed.

A) Assess the level of the client's pain. The nurse should recognize that the pain (phantom limb pain) is real to the client and perform a pain assessment in preparation for pain management. The other options are not examples of acknowledging the client's concern or therapeutic responses to the client in this situation.

Question 8 of 14 The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A) Blood glucose B) Blood urea nitrogen C) Phosphorus D) Platelet count

A) Blood glucose During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment.

When caring for the client receiving chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A) Bruises B) Fever C) Epistaxis D) Pallor E) Petechiae

A) Bruises C) Epistaxis E) Petechiae Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count (thrombocytopenia). Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.

Question 18 of 21 A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? A) Check the dorsalis pedis pulses. B) Administer the prescribed analgesic. C) Place a dressing on the affected area. D) Immobilize the left leg with a splint.

A) Check the dorsalis pedis pulses. The essential nursing action is to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

Which instruction is appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A) Consume a diet high in fiber. B) Bathe in cold water. C) Wear cotton gloves when cooking. D) Make sure shoes are snug.

A) Consume a diet high in fiber. A high-fiber diet will assist with constipation related to neuropathy. The client should bathe in warm not cold water, not hotter than 96° F. Cotton gloves may prevent harm from scratching, but protective gloves should be worn for cooking, washing dishes, and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which intervention does the nurse plan to implement? (Select all that apply.) A) Do not permit fresh flowers or plants in the room. B) Do not allow the client's 16-year-old son to visit. C) Observe for bleeding. D) Teach the client to omit raw fruits and vegetables from the diet. E) Administer pegfilgrastim. F) Assess for fever.

A) Do not permit fresh flowers or plants in the room. D) Teach the client to omit raw fruits and vegetables from the diet. E) Administer pegfilgrastim. F) Assess for fever. Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim and pegfilgrastim, is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well. Raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well. However, very small children, who may get frequent colds and viral infections, may pose a risk.

Question 12 of 18 A client with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the client about which adverse effect of tizanidine? A) Drowsiness B) Hypertension C) Tachycardia D) Hirsutism

A) Drowsiness Adverse effects of tizanidine include drowsiness and sedation because the drug is a centrally acting skeletal muscle relaxant. It does not cause hirsutism, hypertension, or tachycardia.

Question 14 of 14 The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A) Elastase B) Amylase C) Glucose D) Lipase E) Trypsin F) Calcium

A) Elastase B) Amylase C) Glucose D) Lipase E) Trypsin The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) A) Encourage the client to participate in changing the ostomy. B) Encourage the client and family members to express their feelings and concerns. C) Offer to have a person who is coping with a colostomy visit with the client. D) Explain to the client that the colostomy is only temporary. E) Obtain a psychiatric consultation.

A) Encourage the client to participate in changing the ostomy. B) Encourage the client and family members to express their feelings and concerns. C) Offer to have a person who is coping with a colostomy visit with the client. Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.

Question 18 of 20 When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A) Esophageal varices B) Ascites C) Hematuria D) Hemorrhoids E) Fever

A) Esophageal varices B) Ascites D) Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The nurse is teaching a client undergoing radiation therapy for laryngeal cancer. Which potential side effects will the nurse include? (Select all that apply.) A) Fatigue B) Difficulty urinating C) Change in taste D) Difficulty swallowing E) Changes in hair color F) Changes in skin of the neck

A) Fatigue C) Change in taste D) Difficulty swallowing F) Changes in skin of the neck Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific. The larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair, but this does not normally occur with radiation therapy. Difficulty urinating is not a side effect of radiation for laryngeal cancer.

Question 15 of 18 A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A) Help the client sit up. B) Check for fecal impaction. C) Loosen the client's clothing. D) Insert a straight catheter.

A) Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A) Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% B) 5000 white blood cells/mm3 (5 × 109/L) C) 250,000 platelets/mm3 (250 × 109/L) D) Potassium level of 2.9 mEq/L (2.9 mmol/L) and diarrhea

A) Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia. The client with a hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% has anemia demonstrated by low hemoglobin and hematocrit levels. The client with diarrhea and a potassium level of 2.9 mEq/L (2.9 mmol/L) has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 (250 × 109/L), and the client with 5000 white blood cells/mm3 (5 × 109/L) demonstrate normal values.

Question 4 of 15 The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which vital sign change will the nurse expect for this client? A) Hypotension B) Tachypnea C) Oxygen desaturation D) Bradycardia

A) Hypotension The client who is vomiting profusely is losing fluids from the body causing dehydration. A client who is dehydrated has hypovolemia resulting in hypotension and tachycardia.

When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A) Infection B) Drug toxicity C) Polycythemia D) Dose-limiting side effects

A) Infection The lowest point of bone marrow function is referred to as the nadir- risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of RBC's, typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction.

Question 17 of 18 The nurse is teaching a client starting on fingolimod to treat multiple sclerosis about the drug's possible side and adverse effects. Which effects will the nurse include in the teaching? (Select all that apply.) A) Infection B) Hypertension C) Diarrhea D) Tachycardia E) Facial flushing F) Nausea/vomiting

A) Infection C) Diarrhea E) Facial flushing F) Nausea/vomiting The nurse teaches the client and family to monitor the client's pulse because fingolimod causes bradycardia rather than tachycardia. Most oral immunomodulating drugs cause facial flushing, GI disturbances, and decreased white blood cell count that can cause the client to be at risk for infection.

Question 9 of 21 The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? A) Inspect the pins to monitor for infection and do not remove crusts. B) Make sure that the wound is managed using a moist wound healing method. C) Keep the leg covered to keep the extremity warm to promote circulation. D) Keep the extremity elevated to three pillows while in bed or in a chair.

A) Inspect the pins to monitor for infection and do not remove crusts. An external fixator is a series of pins attached to a metal frame to hold the bone ends in place while the wound can be managed. The nurse would frequently monitor the pin insertion sites for signs and symptoms of infection. Crusting that occurs at the sites should not be removed because it helps seal the open pin site areas to prevent infection. Leg elevation is important but the client would not necessarily need three pillows.

Question 15 of 16 A client with obesity has been taking orlistat as prescribed for 4 weeks but has only lost 10 lb (4.5 kg). The health care provider doubles the dosage and asks the nurse to provide further teaching. What behavioral change does the nurse include in the teaching plan? (Select all that apply.) Select all that apply. A) Keep a daily food diary. B) Set daily reasonable goals for eating. C) Increase exercise. D) Identify emotional and situational factors that stimulate eating. E) Identify a healthy individual that can be role-modeled.

A) Keep a daily food diary. B) Set daily reasonable goals for eating. C) Increase exercise. D) Identify emotional and situational factors that stimulate eating. Techniques the nurse includes in the teaching plan are keeping a record of foods eaten (food diary) (to look at daily trends), identifying emotional and situational factors that stimulate eating (which can be modified after identification), and increasing exercise (to burn calories). Setting daily reasonable goals helps the client focus on how to be healthy now instead of setting unreasonable future goals that cause the client to give up if not quickly achieved. The client should not look to role-model other people, as what works for them may not work for the client. The client should focus on his or her own behaviors in order to identify trends and make reasonable changes.

Question 3 of 14 The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse's priority intervention when caring for this client? A) Keeping the biliary drainage bag below the level of the catheter-insertion site B) Checking the client's blood glucose frequently to monitor for diabetes C) Managing pain with continuous opioid patient-controlled analgesia (PCA) D) Capping the catheter if it starts to leak around the insertion site

A) Keeping the biliary drainage bag below the level of the catheter-insertion site The client who has an external percutaneous transhepatic biliary catheter drains by gravity and therefore needs to have the drainage bag placed lower that the catheter-insertion site. The catheter is not capped if jaundice or leakage around the catheter site occurs. Opioids are not needed while the client has the catheter

Question 3 of 22 The nurse is planning health teaching for a client starting on donepezil for Alzheimer disease (AD). For which side effect will the nurse teach the family to monitor? A) Low pulse rate B) Elevated body temperature C) Low oxygen saturation D) High blood pressure

A) Low pulse rate Donepezil and other cholinesterase inhibitors can cause bradycardia and possible heart failure. Therefore, the family needs to monitor the client's pulse rate for a decrease.

Question 13 of 16 Which nursing care activity for an undernourished client does the nurse safely delegate to an assistive personnel (AP)? A) Measuring current height and weight B) Determining body mass index (BMI) C) Estimating body fat using skinfold measurements D) Completing the Mini Nutritional Assessment

A) Measuring current height and weight Determining height and weight is the only activity that the nurse can safely delegated to an AP. The nurse is responsible for completing the Mini Nutritional Assessment, determining the client's BMI, and estimating body fat using skinfold measurements, as these assessments fall within the scope of practice of a registered nurse.

Question 14 of 15 The nurse is caring for a client who was recently diagnosed with Helicobacter. pylori infection. Which drugs does the nurse and anticipate would be used for this client to manage the infection? (Select all that apply.) A) Metronidazole B) Lansoprazole C) Azithromycin D) Tetracycline E) Hydroxychloroquine

A) Metronidazole B) Lansoprazole D) Tetracycline Most clients who have this type of infection are prescribed to take a proton pump inhibitor, such as lansoprazole, and two antimicrobial drugs, such as metronidazole and tetracycline. Clarithromycin and amoxicillin may be used as alternative antibiotics.

Question 11 of 21 A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A) Monitor neuromuscular status for decreased circulation and sensation in the extremity. B) Check the fit of the cast by inserting a tongue blade between the cast and the skin. C) Apply a heating pad for 15 to 20 minutes four times daily to help with pain. D) Keep the cast covered with a soft towel to help it to dry quickly.

A) Monitor neuromuscular status for decreased circulation and sensation in the extremity. The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge. The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. The cast dries quickly because it is made of synthetic materials.

Question 14 of 18 The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? A) Nifedipine B) Dopamine hydrochloride C) Ziconotide D) Methylprednisolone

A) Nifedipine The nurse anticipates that the primary health care provider will prescribe nifedipine or nitrates for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). If AD is not treated, a hemorrhagic stroke can occur. Dopamine hydrochloride is an inotropic agent used to treat severe hypotension. Methylprednisolone is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

Chapter 54 - Concepts of Care for Patients With Problems of the Biliary System and Pancreas Question 1 of 14 The nurse is caring for a client who states that her mother had "gallbladder problems" and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease? A) Obesity B) Birth control pills C) Infertility D) Advanced age

A) Obesity Obese women who are middle age and have had multiple children are at the highest risk for gallbladder disease, although it can occur in anyone.

Question 8 of 15 The nurse is caring for a client who reports stomach pain and heartburn. Which assessment finding is most significant suggesting the client's ulcer is duodenal and not gastric? A) Pain occurs 1½ to 3 hours after a meal, usually at night. B) The client is a man older than 50 years. C) Pain is worsened by the ingestion of food. D) The client has a malnourished appearance.

A) Pain occurs 1½ to 3 hours after a meal, usually at night. A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m. (0100 and 0200) and occurs 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

Question 6 of 14 Which practice does the nurse include when teaching a client about proper oral hygiene? A) Perform self-examination of the mouth every week, and report any unusual findings. B) Brush the teeth daily and floss as needed. C) Wear dentures that fit a bit loosely for movement when chewing. D) Use mouthwash with alcohol unless lesions are present.

A) Perform self-examination of the mouth every week, and report any unusual findings. The nurse will teach the client that proper oral care involves self-examination of the mouth every week and to report any unusual findings to the Health Care Provider. Clients need to brush teeth and floss every day—not just as needed. Clients are taught to avoid contact with agents that may cause inflammation of the mouth (such as, alcohol-based mouthwashes). Dentures should fit snugly, not loosely.

Chapter 40 - Concepts of Care for Patients With Problems of the Central Nervous System - The Spinal Cord Question 1 of 18 A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for the client at this time? A) Positioning the client to maximize ventilation potential B) Taking vital signs every 2 hours C) Inserting an indwelling urinary catheter D) Monitoring the client's nutritional status

A) Positioning the client to maximize ventilation potential The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3 to C5) innervate the phrenic nerve, controlling the diaphragm.

Question 13 of 22 The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A) Positions the client on the side. B) Restrains the client. C) Forces a tongue blade in the mouth. D) Documents the length and time of the seizure.

A) Positions the client on the side. When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway. Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

Which client problem does the nurse determine as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A) Potential for injury related to sensory and motor deficits B) Altered sexual function related to erectile dysfunction C) Potential for lack of understanding related to side effects of chemotherapy D) Potential for ineffective coping strategies related to loss of motor control

A) Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. Every chemotherapy client needs to be taught related side effects of chemotherapy. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.

The nurse is teaching the client about skin protection during radiation therapy. What teaching will the nurse include? (Select all that apply.) A) Protect the area by wearing clothing. B) Avoid all lotions to the area. C) Avoid exposure to sun and heat. D) Do not remove the ink markings on your skin. E) Try to take walks in the early morning or later evening. F) Do not wash the irradiated area.

A) Protect the area by wearing clothing. C) Avoid exposure to sun and heat. D) Do not remove the ink markings on your skin. E) Try to take walks in the early morning or later evening. The client can wash the irradiated area daily with either water or a mild soap. Ink or dye used to mark the radiation area should not be removed. The area should be protected by wearing soft clothing over the site, avoiding exposure to the sun and heat. Lotions can be used as long as they are approved by the radiation team. Walking in the early morning or late evening is a good way to avoid more intense sun.

Question 2 of 22 The nurse is caring for a client with early stage (stage 1) Alzheimer disease (AD). Which nursing action is most appropriate when caring for this client? A) Provide a structured environment. B) Use validation therapy. C) Give a cholinesterase inhibitor. D) Refer the client to the social worker.

A) Provide a structured environment. The client who has stage 1 AD needs reality orientation rather than validation. A structured, consistent environment assists the client in self-care and prevents anxiety that could result from unfamiliar routines or environments. Drug therapy and social work referrals are appropriate for some clients, but all clients need structure.

When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A) Providing oral care with a disposable mouth swab B) Maintaining NPO until the lesions have resolved C) Encouraging oral care with commercial mouthwash D) Administering a biological response modifier

A) Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care, mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells- mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition and hydration are important during cancer treatment - a local anesthetic may be prescribed.

Question 12 of 14 The nurse is teaching a client how to maintain effective oral health. Which measure does the nurse include in the teaching plan? (Select all that apply.) A) Regular dental checkups. B) Eating a balanced diet. C) Use of mouthwashes containing alcohol. D) Managing stress as much as possible. E) Ensuring that dentures are slightly loose-fitting.

A) Regular dental checkups. B) Eating a balanced diet. D) Managing stress as much as possible. Regular dental checkups are important, so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis. Mouthwashes that contain alcohol may irritate tissues and cause inflammation, and should be avoided. Dentures must be in good repair and need to fit properly, not loosely.

Question 6 of 14 A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A) Respiratory assessment B) Cardiovascular assessment C) Abdominal assessment D) Pain intensity assessment

A) Respiratory assessment As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS).

Question 17 of 20 When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A) Right upper quadrant tenderness B) Itching C) Recent influenza infection D) Brown stool E) Tea-colored urine

A) Right upper quadrant tenderness B) Itching E) Tea-colored urine Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine

Question 19 of 20 The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) A) Smoking B) Alcohol C) Illicit drugs D) Acetaminophen E) Sodium F) Protein

A) Smoking B) Alcohol C) Illicit drugs D) Acetaminophen Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver.

Question 20 of 22 A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.) A) Suction equipment at the bedside B) Continuous sedation C) Intravenous (IV) access D) Bite block at the bedside E) Side rails raised

A) Suction equipment at the bedside C) Intravenous (IV) access E) Side rails raised Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside, and raised side rails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded side rails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Question 2 of 16 A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents a client injury during repositioning? A) Using a weight-rated extra-wide bed for the client B) Administering pain medication C) Monitoring skinfold areas and keeping them clean and dry D) Making sure not to move the client's nasogastric (NG) tube

A) Using a weight-rated extra-wide bed for the client The most effective way to reposition a postoperative bariatric client and prevent injury is to use a special weight-related extra wide bed. This will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during repositioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent repositioning injuries.

Question 12 of 14 The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication? A) Wipe your lips after taking pancrelipase. B) Take pancrelipase before meals. C) Administer pancrelipase before taking an antacid. D) Chew tablets before swallowing.

A) Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.

Question 2 of 14 While undergoing radiation treatment for oral cancer, a client develops xerostomia. What collaborative resource does the nurse suggest for this client's care? A) Dentist B) Occupational therapist C) Speech therapist D) Psychiatrist

A)Dentist Xerostomia is the subjective feeling of oral dryness. It is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits.

Question 20 of 21 A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? (Select all that apply.) A)Elevate the left leg above the level of the heart. B) Tell the client to keep his left leg still. C) Apply an elastic wrap or ankle or compression brace. D) Administer morphine via IV push. E) Apply heat to promote blood flow and healing.

A)Elevate the left leg above the level of the heart. B) Tell the client to keep his left leg still. C) Apply an elastic wrap or ankle or compression brace. The nurse follows the RICE approach to emergency care of clients who experience a sports-related injury, which includes rest, ice, compression, and elevation of the affected part. Heat may be used after 24 hours, but ice is needed now to reduce swelling. The client does not need a strong opioid for this injury.

Question 18 of 18 The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment findings would the nurse anticipate if this complication occurs? (Select all that apply.) A) Goose bumps above and/or below the injury level B) Sudden and severe hypertension C) Severe throbbing headache D) Profuse sweating above the injury level E) Nasal congestion and blurred vision F) Facial and skin flushing

ALL OF THE ABOVE All of these findings commonly occur in clients who experience autonomic dysreflexia. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Question 22 of 22 The nurse is caring for a client who has Parkinson disease (PD). What assessment findings would the nurse expect? (Select all that apply.) A) Stooped posture B) Masklike facial expression C) Drooling at times D) Shuffled gait E) Dysarthria F) Muscle rigidity

ALL OF THE ABOVE All of these signs and symptoms commonly occur in clients who have PD. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Question 20 of 20 The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A) Increased serum bilirubin B) Increased lactate dehydrogenase C) Decreased serum albumin D) Increased serum alanine aminotransferase E) Increased aspartate aminotransferase F) Increased serum ammonia

ALL OF THE ABOVE Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products. _______________________________________________________________________________________________

Question 4 of 14 The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy ("lap chole"). What statement by the client indicates a need for further teaching? A) "I will likely need oral pain medications for the first few days after my surgery." B) "I should only be hospitalized for 2 to 3 days after my surgery." C) "I will probably not be at risk for complications from this surgery." D) "I should be able to go back to work in the next week or so."

B) "I should only be hospitalized for 2 to 3 days after my surgery." A "lap chole" surgery has many advantages over the open traditional surgical method, including a short hospital stay, usually same-day surgery, minimal risk for complications, and the ability to achieve pain control by using oral analgesics.

Which client statement allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment? A) "I may lose my hair during this treatment." B) "I will have a radioactive device in my body for a short time." C) "I must be positioned in the same way during each treatment." D) "I will be placed in a semiprivate room for company."

B) "I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific. Because radiation therapy is site-specific. This client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

Chapter 53 - Concepts of Care for Patients With Liver Problems Question 1 of 20 Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A) "The scars on my liver create problems with blood circulation." B) "My liver is scarred, but the cells can regenerate themselves and repair the damage." C) "Because of the scars on my liver, blood clotting and blood pressure are affected." D) "Cirrhosis is a chronic disease that has scarred my liver."

B) "My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.

Question 5 of 15 A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? A) "No, they probably won't be useful. You should use only prescription medications in your treatment plan." B) "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." C) "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe." D) "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them."

B) "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the client must consult his or her primary health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her primary health care provider.

Question 21 of 21 A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? (Select all that apply.) A) Urinary tract infection (UTI) B) Acute compartment syndrome (ACS) C) Fat embolism syndrome (FES) D) Osteomyelitis E) Heart failure

B) Acute compartment syndrome (ACS) C) Fat embolism syndrome (FES) D) Osteomyelitis ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Heart failure is not a potential complication for this client- pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

Question 9 of 14 A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A) Assist the client to assume a position of comfort. B) Administer opioid analgesic medication. C) Do not administer food or fluids by mouth. D) Measure intake and output every shift.

B) Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse is caring for a client with hyperuricemia associated with tumor lysis syndrome (TLS). Which medication does the nurse anticipate being prescribed? A) Radioactive iodine-131 B) Allopurinol C) Recombinant erythropoietin D) Potassium chloride

B) Allopurinol The nurse expects allopurinol to be prescribed, because allopurinol decreases uric acid production and is indicated in TLS. TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous because the client is already hyperkalemic. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.

Question 10 of 21 The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? A) Ensure that each crutch fits firmly into the client's armpit. B) Be sure that the top of each crutch is well padded. C) Use the crutch on the affected side only. D) Check to see how many steps the client can take with the crutches.

B) Be sure that the top of each crutch is well padded. The crutches are used a set and require that the nurse ensure that the client does not develop axillary nerve damage. The tops of the crutches should be well padded and should be at least 2 to 3 finger-breadths below the armpit.

Question 9 of 20 The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A) Decreased ascitic fluid B) Changes in consciousness or behavior C) Fatigue and weakness D) Decreased pulse rate

B) Changes in consciousness or behavior Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak.

Question 13 of 14 A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) A) Ensure that drainage color is clear. B) Check blood glucose often. C) Place the client in the supine position. D) Check bowel sounds and stools. E) Monitor mental status.

B) Check blood glucose often. D) Check bowel sounds and stools. E) Monitor mental status. To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

Chapter 50 - Concepts of Care for of Patients With Stomach Disorders Question 1 of 15 The nurse and the registered dietitian nutritionist are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is most appropriate for this client? A) Liver, bacon, and onions B) Chicken and white rice C) Chicken salad on whole wheat bread D) Green vegetable salad with buttermilk ranch dressing

B) Chicken and white rice Chicken and rice is the most appropriate sample meal for this client. It is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not have much mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The client may have whole wheat bread only in very limited amounts.

Question 2 of 21 A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? A) Chronic osteomyelitis B) Complex regional pain syndrome C) Severe osteoporosis D) Compartment syndrome

B) Complex regional pain syndrome When pain is not managed appropriately or interventions are not implemented to prevent complex regional pain syndrome (CRPS), the client is at risk for developing CRPS, a chronic debilitating complication of traumatic injury.

Question 7 of 20 The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A) Increased blood pressure B) Decreased weight C) Increased pulse D) Decreased pain

B) Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

Question 8 of 16 An older adult with severe rheumatoid arthritis in the upper extremities is undernourished. What does the nurse anticipate may be a contributing factor? A) Inadequate income to purchase sufficient food B) Diminishing ability to manipulate eating utensils C) A decrease in appetite D) Metabolic requirements that are increased due to immobility

B) Diminishing ability to manipulate eating utensils The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils. No evidence suggests that the client is experiencing a decrease in appetite or is financially unable to purchase adequate food. No evidence suggests that the client is immobile. Metabolic requirements would decrease, not increase, with less mobility.

Question 16 of 16 The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take after reviewing the client's laboratory report, and seeing an increase in triglycerides? (Select all that apply.) Select all that apply. A) Document the findings and continues to monitor. B) Discontinue the IVFE infusion. C) Slow the rate of flow of the IVFE infusion. D) Offer small bites of oral foods. E) Notify the health care provider.

B) Discontinue the IVFE infusion. E) Notify the health care provider. If a client receiving an IVFE nutritional supplement develops fever, increased triglycerides, clotting problems, or symptoms of multi-system organ failure, the nurse must discontinue the IVFE and notify the HCP. These symptoms may indicate fat overload syndrome, especially in a critically ill patient. Only documenting the findings and continuing to monitor could have serious repercussions for this client. Slowing the rate of flow of the IVFE infusion, or offering small bites of oral foods, can also present a serious safety risk. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Question 11 of 20 The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? A) Being exposed to blood or blood products B) Eating contaminated food or water C) Having unprotected sex D) Sharing needles for illicit drugs

B) Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.

Question 15 of 15 The nurse is assessing a client who is suspected of having early gastric cancer. What signs and symptoms would the nurse expect? (Select all that apply.) A) Fatigue B) Feeling of fullness C) Dyspepsia D) Weakness E) Weight loss F) Nausea and vomiting

B) Feeling of fullness C) Dyspepsia The client who has early gastric cancer usually has no or few signs and symptoms, but may have dyspepsia and a feeling of fullness. More distressing changes are manifested when the cancer becomes more advanced.

Question 5 of 22 Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A) Avoid large crowds. B) Get the meningococcal vaccine. C) Take a high dose vitamin C daily. D) Take prophylactic antibiotics.

B) Get the meningococcal vaccine. The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individual's ages 16 to 21 years have the highest rates of meningococcal infection and need to be immunized against the virus. Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

Question 17 of 22 The nurse is providing medication instructions for a client for whom phenytoin has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A) Grape juice B) Grapefruit juice C) Apple juice D) Prune juice

B) Grapefruit juice The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity. Apple, grape, and prune juices are not contraindicated for a client taking phenytoin.

Question 2 of 15 The nurse is caring for a client who has a gastric ulcer. For which potentially life-threatening complication would the nurse monitor for this client? A) Hypokalemia B) Hemorrhage C) Nausea and vomiting D) Infection

B) Hemorrhage Clients who have gastric ulcers are particularly at risk for upper GI bleeding, or hemorrhage. They may also experience nausea and vomiting causing dehydration. However, hemorrhage is most serious.

Question 7 of 22 A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A) Telling his wife what the client needs B) Involving the client and his wife in developing a plan of care C) Writing up a detailed plan of care according to standards D) Setting up visitations by a home health nurse

B) Involving the client and his wife in developing a plan of care The discharge plan most effective when discharging a client home with his spouse is to involve both the client and his wife in developing the plan of care. Involving the client and spouse in drawing up a plan of care is the best way to ensure success with the management plan. Home health nurse visitations are generally helpful but may not be needed for this client. The management plan must be collaborative and include not only the spouse but also the client to ensure buy-in. Evidence-based guidelines would be utilized.

Question 4 of 14 A client with oral cancer who is to have a radical neck dissection reports being depressed. What is the nurse's priority response? A) Suggest seeking support from a community group. B) Listen to the client's concerns. C) Explain the grieving process. D) Reassure that it is normal to feel depressed about the diagnosis.

B) Listen to the client's concerns. The nurse's priority response is to listen to the client and allow him or her to process feelings. After the client has processed feelings, he or she is more open to learning about the normalcy of feeling depressed about this diagnosis, understanding the grieving process, and considering referral to a community group of clients undergoing a similar experience.

The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A) Observe for motor deficits. B) Monitor weight. C) Monitor platelets. D) Trend red blood cells and hemoglobin and hematocrit.

B) Monitor weight. Cachexia results in extreme body wasting, malnutrition, and severe weight loss. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.

Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A) Naloxone B) Ondansetron C) Diazepam D) Morphine

B) Ondansetron Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Lorazepam, a benzodiazepine, may also be given for nausea. Morphine is a narcotic analgesic or opiate and may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only.

Question 13 of 14 The nurse is caring for a client diagnosed with aphthous (Canker sore) ulcers. Which food will the nurse recommend that the client avoid? (Select all that apply.) A) Apples B) Pasta C) Baked potato D) Nuts E) Cheese

B) Pasta C) Baked potato D) Nuts E) Cheese Aphthous ulcers (canker sores) are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. The nurse tells the client that certain foods such as cheese, nuts, potatoes, and foods containing gluten (like pasta) may trigger allergic responses that cause aphthous ulcers and should be avoided. Apples and bananas are not acidic and do not trigger allergic responses that cause aphthous ulcers.

Question 9 of 22 A client with Parkinson disease (PD) reports having auditory hallucinations. What drug would the nurse anticipate may be prescribed for the client? A) Ubrogepant B) Pimavanserin C) Phenytoin D) Levodopa

B) Pimavanserin Pimavanserin is a drug that is used when clients with PD have hallucinations. Phenytoin is used to manage seizures and ubrogepant is used for clients who have migraine headaches. Levodopa, usually in combination with carbidopa, is a commonly used drug for most clients at some time for their PD.

Question 9 of 16 A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begin to experience a seizure, how does the nurse interpret this client's signs and symptoms? A) Abdominal distention is present. B) Refeeding syndrome may be occurring. C) Severe hyperglycemia is present. D) The enteral tube is dislodged.

B) Refeeding syndrome may be occurring. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to clients who are starved, severely malnourished, or metabolically stressed due to severe illness. Symptoms of refeeding syndrome include heart failure, peripheral edema, rhabdomyolysis, seizures, and hemolysis. If the enteral tube becomes misplaced or dislodged, the client may develop aspiration pneumonia displayed by increased temperature, increased pulse, dehydration, diminished breath sounds, and shortness of breath. Abdominal distention is most frequently accompanied by nausea and vomiting. In refeeding syndrome, insulin secretion decreases in response to the physiologic changes in the body, so hyperglycemia is not present. When refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels, resulting in hypoglycemia.

Review Questions - NCLEX® Examination - Chapter 20 The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome will the nurse teach the client is the goal of palliative surgery? A)Prolonging the client's survival time B) Relief of symptoms or improved quality of life C) Allowing other therapies to be more effective D) Cure of the cancer

B) Relief of symptoms or improved quality of life The focus and goal of palliative surgery is to help relieve symptoms of end-stage cancer and improve quality of life during the survival time.

Question 7 of 15 The nurse is caring for a client who is diagnosed with a perforated duodenal ulcer. Which assessment finding would the nurse expect? A) Positive McBurney point B) Rigid, board-like and tender abdomen C) Nausea and profuse vomiting D) Absent bowel sounds in all four quadrants

B) Rigid, board-like and tender abdomen Perforation allows intestinal contents to escape into the peritoneal cavity causing peritonitis. The classic assessment finding for a client who has peritonitis is a rigid, board-like abdomen that is tender or painful.

Question 19 of 22 The nurse is caring for a client diagnosed with vascular dementia. The nurse recognizes that which health problem is associated with this type of dementia? A) Epilepsy B) Stroke C) Meningitis D) Migraines

B) Stroke Vascular dementia is typically caused by strokes or other cranial vascular disease. The exact cause of Alzheimer disease is not known.

Question 16 of 20 When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A) Elevated magnesium B) Swollen abdomen C) Prolonged partial thromboplastin time D) Elevated amylase level E) Currant jelly stool F) Icterus of skin

B) Swollen abdomen C) Prolonged partial thromboplastin time F) Icterus of skin Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

Question 12 of 16 The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A) Reports pain of "6" on 0-10 scale when being repositioned. B) Urine output total is 15 mL for the past 2 hours. C) Skin under the panniculus is excoriated. D) Bowel sounds are not audible in all quadrants.

B) Urine output total is 15 mL for the past 2 hours. The nurse reports a urine output total of 15 mL for the past 2 hours. Normal urine output needs to be at least 30 mL/hr. Oliguria (scant urine output) may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure. Inaudible bowel sounds would typically require intervention, but on the day of surgery, absent bowel sounds are an expected finding. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require an immediate report to the surgeon.

Question 19 of 21 Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? A) Lungs for bilateral normal breath sounds B) Urine specimen to assess for the red blood cells C) Pain score and level of alertness D) Skin to evaluate lacerations and abrasions

B) Urine specimen to assess for the red blood cells It is most important for the nurse to determine the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries. Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

Question 9 of 18 The nurse is collaborating with the rehabilitation therapist to improve mobility skills for a client with a complete high-level spinal cord injury. Which technique is appropriate for this client? A) Use of a mechanical lift to get the client out of bed B) Use of a sliding board (slider) to transfer from bed to a chair C) Use of parallel bars to facilitate ambulation D) Use of a walker to promote balance and prevent muscle atrophy

B) Use of a sliding board (slider) to transfer from bed to a chair The client who has a complete high-level, or cervical, spinal cord injury is tetraplegic (quadriplegic) meaning that he or she does not have control over any extremity. The client has shoulder movement allowing the client to use a sliding board as a "bridge" between the bed and chair.

Question 3 of 14 A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? A) This condition is common but is temporary. B) Use saliva substitutes, especially when eating dry foods. C) This indicates a complication of therapy. D) Use lozenges and hard candies to prevent dry mouth.

B) Use saliva substitutes, especially when eating dry foods. Xerostomia is a common effect of oral irradiation. Clients should be advised to use saliva substitutes. The condition is common, but often permanent. Dry mouth is a side effect of therapy, not a symptom of complications. Taking frequent sips of water is the preferred method of treating xerostomia during radiation therapy.

Which intervention will the oncology nurse use to prevent disseminated intravascular coagulation (DIC)? A) Monitoring platelets B) Using strict aseptic technique to prevent infection C) Administering packed red blood cells D) Administering low-dose heparin therapy for clients on bedrest

B) Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. The oncology nurse must use strict asepsis to prevent any infection. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

Question 16 of 21 A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? A) "I need to make sure I have an ergonomically sound computer station." B)"I need to exercise repetitively to strengthen my wrists." C) "I should stretch my fingers and wrists frequently during the day." D) "I may need to wear a wrist splint when my wrist gets inflamed."

B)"I need to exercise repetitively to strengthen my wrists." All of these statements are correct except that CTS is caused by repetitive motion such as that caused by working every day on computers. Repetitive exercises would therefore not be appropriate.

Question 4 of 21 Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? A) "Inspect the pins in the traction for signs of infection." B) "Remove the boot every shift to inspect the skin." C) "Do not allow the traction weights to rest on the ground." D) "Remove traction weights when turning the client."

C) "Do not allow the traction weights to rest on the ground." Although Buck's traction is not used commonly today because clients have surgical hip repairs to reduce pain, for some clients such as this client, it is used short term until surgery can be performed. The AP should allow the weights to hang freely and not remove them. There are no pins and the boot can be removed by the nurse for skin inspection.

Question 13 of 15 The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A) "I cannot drink alcohol at all." B) "I will need to avoid sweetened fruit juice beverages." C) "I can eat ice cream in moderation." D) "It is okay to have a serving of sugar-free pudding."

C) "I can eat ice cream in moderation." A need for further teaching about dietary changes related to dumping syndrome is indicated when the client says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.

Question 6 of 18 A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? A) "I'll need to wear special stockings after the procedure." B) "I can go home 48 hours after the procedure." C) "I can go home the day of the procedure." D) "I'll have a drain in place after the procedure."

C) "I can go home the day of the procedure." The statement that indicates the client correctly understands preoperative teaching of a microdiskectomy is "I can go home the day of the procedure." A microdiskectomy is considered minimally invasive surgery (MIS) and does not typically require an in client hospital stay. The client who undergoes a minimally invasive surgery does not have to wait 48 hours after the procedure to return home, will not have a drain in place after the procedure, and will not need to wear special stockings after the procedure. These steps are used in the case of traditional open laminectomy, not MIS.

Question 6 of 22 The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A) "I need to use fake sugar in my coffee." B) "I can still eat Chinese food." C) "I should not miss any meals." D) "It is okay to drink a few wine coolers."

C) "I should not miss any meals." The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified. Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

Question 11 of 22 A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan. Which statement by the client indicates an understanding of the nurse's discharge instructions? A) "Birth control is not needed while taking sumatriptan." B) "Sumatriptan can be taken as a last resort." C) "I will report any chest pain right away." D) "St. John's wort can also be taken to help my symptoms."

C) "I will report any chest pain right away." The client comment that shows that she understands the discharge instructions is that any chest pain must be reported right away. Chest pain must be reported immediately with the use of sumatriptan because triptans cause vasoconstriction. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans would not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression. Sumatriptan must be taken as soon as migraine symptoms appear.

Question 11 of 18 The nurse is providing instructions to a client with a cervical spinal cord injury about caring for the halo fixator device. The nurse plans to include which instructions? A) "Avoid using a pillow under the head while sleeping." B) "Begin driving 1 week after discharge." C) "Keep straws available for drinking fluids." D) "Swimming is recommended to keep active."

C) "Keep straws available for drinking fluids." The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth. The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.

Question 8 of 22 The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A) "Establishing goals and a daily plan can help." B) "Can't you take care of your spouse?" C) "Make sure you take some time off and take care of yourself." D) "That's not a very nice thing to say."

C) "Make sure you take some time off and take care of yourself." The nurse's best response to the spouse of the client with dementia is to encourage the wife to take some time off to take care of herself. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan may be helpful to the situation but is not responding to the spouse's need. Reprimanding the spouse does not validate his or her feelings and does not allow the nurse to further explore the statement.

Question 4 of 18 A client with possible multiple sclerosis asks the nurse to explain why she has to have a visual evoked response (VER) test. What statement by the nurse is correct about this diagnostic test? A) "A group of electrodes will be placed on your scalp so to see how your eyes react." B) "You will have to lie very still in a tube for the magnetic imaging of your head and neck." C) "This test will help determine how well the nerves in your eyes transmit a signal." D) "A contrast medium will be used to visualize any changes in your brain."

C) "This test will help determine how well the nerves in your eyes transmit a signal." The VER is a noninvasive test that determines how well nerve transmission occurs along the optic nerve pathways.

Question 5 of 21 The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? A) "Avoid rigorous exercise." B) "Avoid contact sports." C) "Wear helmets when riding a motorcycle." D) "Avoid driving in inclement weather."

C) "Wear helmets when riding a motorcycle." Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, but it is also opposed to what many health care professionals recommend to maintain health. Question 6 of 21 An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A) Keep the client's heels off the bed at all times. B) Reposition the client every 3 to 4 hours. C) Avoid the use of antiembolism stockings. D) Administer pain medication before deep-breathing exercises. : A) Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

Question 2 of 14 A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test? A) "This test measures how inflamed your gallbladder and liver may be." B) "You may eat and drink as much as you'd like before you have this test." C) "You will have to lie still for some time while the camera is very close to your body." D) "I need to know if you are allergic to shellfish because the contrast will be iodine-based."

C) "You will have to lie still for some time while the camera is very close to your body." The HIDA scan requires the injection of radioactive medium which is given about 20 minutes before a large camera is positioned very close to the body. The camera moves to assess for biliary flow and to determine if any obstruction is present.

The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A) Lung B) Veins of the legs C) Abdominal cavity D) Heart

C) Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.

Question 17 of 21 A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A) Surgical repair of the rotator cuff B) Patient-controlled analgesia with morphine C) Activity limitations for the affected arm D) Prescribed exercises of the affected arm

C) Activity limitations for the affected arm The immediate conservative treatment for this client is to limit activity in the injured arm. Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

Question 8 of 20 Which action by the nurse would most likely help to relieve symptoms associated with ascites? A) Monitoring serum albumin levels B) Lowering the head of the bed C) Administering oxygen therapy D) Administering intravenous fluids

C) Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

The nurse is caring for a client who is receiving rituximab for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A) Alopecia B) Fever C) Allergy D) Chills

C) Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab), and the nurse must be aware of any allergic reactions the client may exhibit. Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.

NCLEX® Examination - Chapter 39 Question 1 of 22 The nurse is assessing a client who was diagnosed with Alzheimer disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document? A) Aphasia B) Apraxia C) Anomia D) Agnosia

C) Anomia Anomia is the inability to find words for objects, places, and events, and is a common assessment finding in clients with early AD. Aphasia is a general problem with speaking, understanding, to both. Apraxia is the inability to use an object correctly and agnosia, a later AD finding, is a lack of sensory comprehension.

Question 4 of 16 How does the nurse accurately calculate a client's body mass index (BMI)? A) BMI = weight (lb)/height (in inches)2 B) BMI = weight (kg)/height (in meters) C) BMI = weight (kg)/height (in meters)2 D) BMI = weight (lb)/height (in meters)

C) BMI = weight (kg)/height (in meters)2 The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)2.

Question 16 of 22 The nurse is reviewing the history of a client who has been prescribed topiramate for prevention of migraines. The nurse plans to contact the primary health care provider if the client has which condition? A) Diabetes mellitus B) Hypothyroidism C) Bipolar disorder D) Glaucoma

C) Bipolar disorder The nurse contacts the primary health care provider after reviewing the history of a client with bipolar disorder who has been prescribed topiramate. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder. Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

Question 10 of 14 A client reports ongoing episodes of "heartburn." Which food will the nurse recommend that the client eliminate from the diet? A) Steak B) Carrots C) Chocolate D) Popcorn

C) Chocolate Foods that decrease esophageal sphincter pressure, such as fatty foods, caffeine, and chocolate, should be avoided. Steak, carrots, and popcorn do not decrease esophageal sphincter pressure.

Question 10 of 16 A client receiving total parenteral nutrition (TPN) exhibits symptoms of heart failure (CHF) and pulmonary edema. Which complication of TPN does the nurse recognize that the client is experiencing? A) Potassium imbalance B) Fluid volume deficit C) Fluid volume overload D) Calcium imbalance

C) Fluid volume overload This client is most likely experiencing fluid volume overload. Heart failure and pulmonary edema are symptoms of this condition. Calcium imbalance, fluid volume deficit, and potassium imbalance do not manifest with heart failure and pulmonary edema. The nurse tells the client to expect loose stools, abdominal cramps, and nausea. These are side effects unique to orlistat (Xenical). Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), and phendimetrazine (Bontril).

Question 13 of 21 A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs? A) Absence of erythema and tenderness at the surgical site B) Ability to flex and extend the right knee C) Large amount of serosanguineous or bloody drainage D) Mild to moderate pain controlled with prescribed analgesics

C) Large amount of serosanguineous or bloody drainage A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

Question 14 of 20 What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A) Drink only bottled water and avoid ice. B) Avoid sharing the bathroom with the client. C) Members of the household must not share toothbrushes. D) The client must not consume alcohol.

C) Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

Question 12 of 20 When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A) Clients who work with shellfish. B) Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C) Men who engage in sex with men. D) Clients traveling to a third-world country.

C) Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

Question 3 of 15 The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which acid-base imbalance will the nurse expect for this client? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

C) Metabolic alkalosis Gastric contents are rich in acid (hydrogen and chloride ions). When this fluid is lost through vomiting, the client has less acid causing an alkalotic state.

Question 3 of 21 A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? A) Check the client's blood pressure frequently. B) Monitor the client's pain level. C) Monitor the client's respiratory rate. D) Perform circulation checks before and after the procedure.

C) Monitor the client's respiratory rate. The drugs used for moderate sedation can suppress respiratory rate which requires constant monitoring during the procedure. The client should not feel any pain.

Question 6 of 16 A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? A) Calculates his body mass index (BMI). B) Measures his accurate height and weight measurements. C) Obtains a 24-hour recall (diary) of his food intake. D) Records a 24-hour diary of his physical activities.

C) Obtains a 24-hour recall (diary) of his food intake. The most effective way to plan nutritional care for a client is to obtain a 24-hour recall of food intake. This will determine the client's food preferences and eating patterns so that they can be incorporated into the diet. Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.

Question 7 of 14 A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A) Cirrhosis B) Crohn disease C) Peritonitis D) Peptic ulcer disease

C) Peritonitis Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage.

Question 8 of 14 When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the assistive personnel (AP)? A) Instruct how to use nystatin oral rinses. B) Assist with making appropriate dietary choices that do not irritate tissues. C) Provide oral care using a soft toothbrush. D) Inspect the oral mucosa for evidence of oral candidiasis.

C) Provide oral care using a soft toothbrush. Providing oral care using a soft toothbrush for a client with oral lesions is an appropriate assignment for an AP. Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

Question 7 of 14 The nurse is providing instructions to a client with a history of stomatitis. Which instructions does the nurse include in the teaching plan? A) Encourage the client to eat acidic foods to decrease bacteria. B) Mouth care should be performed twice daily at the maximum. C) Rinse the mouth frequently with warm saline or sodium bicarbonate. D) Use a medium-bristled toothbrush for oral care.

C) Rinse the mouth frequently with warm saline or sodium bicarbonate. Rinsing the mouth frequently with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain. Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed, at the minimum of twice daily. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush, not medium-bristled one, needs to be used for oral care.

Chapter 49 - Concepts of Care for Patients With Oral Cavity and Esophageal Problems Which food does the nurse teach a client undergoing chemotherapy with secondary stomatitis to avoid? A) Broiled fish B) Ice cream C) Salted pretzels D) Scrambled eggs

C) Salted pretzels Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain. Cool or cold foods and foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

Question 15 of 22 A client receiving propranolol as preventive therapy for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? A) Warm sensation B) Tingling feelings C) Slow heart rate D) Dry mouth

C) Slow heart rate The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider. Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

Question 11 of 14 The community nurse is discussing risk factors for esophageal cancer with a group of clients. Which client behavior requires further teaching? A) Eats a small snack each night before bedtime. B) Walks at the shopping mall three times weekly. C) Smokes 1/3 of a pack of cigarettes daily. D) Elevates pillows at night.

C) Smokes 1/3 of a pack of cigarettes daily. Tobacco use is one of the primary risk factors for esophageal cancer. This client behavior requires teaching about lifestyle risks that could increase the risk for esophageal cancer.

Question 12 of 15 The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? A) Administer antianxiety medication. B) Initiate enteral nutrition. C) Start intravenous (IV) fluids, D) Administer histamine (H2) antagonist.

C) Start intravenous (IV) fluids The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.

Question 10 of 15 The nurse is planning health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? A) Crushing the drug and mixing in applesauce B) Avoiding alcohol while taking this drug C) Taking the drug 30 minutes before a meal D) Taking the drug when the client has gastric pain

C) Taking the drug 30 minutes before a meal This drug is a proton pump inhibitor and is activated by the presence of food in the stomach. Therefore, it should be taken before a meal.

Question 8 of 21 Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? A) Talking with a psychiatrist about the amputation B) Engaging in diversional activities to avoid focusing on the amputation C) Talking with an amputee close to the client's age who has a similar amputation D) Drawing a picture of how the client sees him- or herself

C) Talking with an amputee close to the client's age who has a similar amputation Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

Question 5 of 14 The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? A) Sausage and scrambled eggs B) Steak and french fries C)Turkey sandwich on wheat bread D)Fried chicken and mashed potatoes

C) Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones. Steak, french fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

Question 7 of 16 Based on nutritional screening findings and assessments, which client does the nurse identify that meets criteria for surgical treatment of obesity? A) Woman with a BMI of 38, weight 50% above ideal body weight B) Man with a body mass index (BMI) of 40, weight 75% above ideal body weight C) Woman with a BMI of 42, weight 100% above ideal body weight D) Man with a BMI of 41, weight 80% above ideal body weight

C) Woman with a BMI of 42, weight 100% above ideal body weight The client who will be most successful with surgical intervention is the client with a BMI of 40 or more and a weight 100% above the ideal body weight. The other clients do not have a high enough BMI-to-weight ratio to be considered for surgical intervention.

Question 11 of 14 After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A) Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B) Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. D) Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography.

C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

Question 2 of 20 The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor A) deep vein thrombosis. B) jaundice. C) hematemesis. D) pressure injury.

C) hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.

Question 6 of 15 The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A) "I will need to take vitamin B12 shots for the rest of my life." B) "I should eat small meals about six times a day." C) "It is okay to continue to drink coffee in the morning when I get to work." D) "I should avoid alcohol and tobacco of any type."

D) "I should avoid alcohol and tobacco of any type." The client's statement that he or she needs to avoid alcohol and tobacco shows that the client correctly understands the nurse's instructions. The client also needs to eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

Question 7 of 21 A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A) "I can't believe that this has happened to me. I can't stand to look at it." B) "I do not want any visitors while I'm in the hospital." C) "My spouse will be the only person to change my dressing." D) "It will take me some time to get used to this."

D) "It will take me some time to get used to this." Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

Question 8 of 18 A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What would be the appropriate response for the nurse? A) "Only time will tell, but hopefully the client will be able to care for yourself." B) "Every injury is different, and it is too soon to have any real answers right now." C) "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D) "Please request a meeting with the primary health care provider. I can help set that up."

D) "Please request a meeting with the primary health care provider. I can help set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting, however. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

Question 9 of 14 The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A) "My family likes to eat small meals every 3 to 4 hours throughout the day." B) "When I buy meat, I ask for the leanest cut that is available." C) "I quit smoking 6 months ago." D) "Sometimes I wake up gasping for air in the middle of the night."

D) "Sometimes I wake up gasping for air in the middle of the night." Gasping for air upon waking in the middle of the night can be a sign of sleep apnea. The nurse must report this finding to the primary health care provider. Often patients who have one condition (sleep apnea or GERD) also experience the other. Quitting smoking 6 months ago, eating small meals, and eating lean meats are favorable findings that do not need to be reported.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A) Explain that this occurs in some clients and is usually permanent. B) Inform the client that a small glass of wine may help her relax. C) Protect the client from infection. D) Allow the client an opportunity to express her feelings.

D) Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.

Question 4 of 22 A client visits the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. What action would the nurse take next? A) Turn on the lights for a neurologic assessment. B) Assess the client's vital signs. C) Remove the cloth because it can harbor microorganisms. D) Allow the client to remain undisturbed.

D) Allow the client to remain undisturbed. The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening. Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

Question 4 of 20 When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A) Assist the provider to insert a trocar catheter into the abdomen. B) Position the client with the head of the bed flat. C) Encourage the client to take deep breaths and cough. D) Ask the client to void prior to the procedure.

D) Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

Question 13 of 18 A client returns to the neurosurgical floor after undergoing a traditional anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? A) Check the client's ability to void. B) Administer pain medication. C) Assist with ambulation. D) Assess airway and breathing.

D) Assess airway and breathing. The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical diskectomy is to assess the airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing. Administration of pain medication, ambulation, and assessing the client's ability to void are important but are not the highest priority.

Question 14 of 22 A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A) Strict monitoring of hourly intake and output B) Decreasing environmental stimuli C) Managing pain through drug and nondrug methods D) Assessing neurologic status at least every 2 to 4 hours

D) Assessing neurologic status at least every 2 to 4 hours The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2 to 4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status. Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority

NCLEX® Examination - Chapter 55 Question 1 of 16 An older adult client is at risk for undernutrition. Which nursing intervention is appropriate to ensure optimum nutritional intake? A) Administering antiemetics and analgesics after meals B) Reminding APs to allow the client to remain in bed during meals C) Turning on the television during meals to provide distraction D) Assisting the client with toileting and oral care prior to meals

D) Assisting the client with toileting and oral care prior to meals The appropriate intervention to ensure optimum nutritional intake in an older adult client at risk for undernutrition is to assist the client with toileting and oral care prior to meals for comfort and to prevent these from distracting clients from meals. Antiemetics and analgesics should be provided prior to meals. Clients need to be free from distractions while eating. When possible, clients are placed in chairs for eating.

Question 13 of 20 It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A) Right shoulder pain B) Bone marrow suppression C) Polyuria D) Bleeding

D) Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority. Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators is used, the nurse then assesses for bone marrow suppression.

Question 11 of 15 The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs would the nurse expect? A) Temperature from 97.9° to 98.9° F (36.6° to 37.2° C) B) Respiratory rate from 24 to 20 breaths/min C) Apical pulse from 80 to 72 beats/min D) Blood pressure from 140/90 to 110/70 mm Hg

D) Blood pressure from 140/90 to 110/70 mm Hg A decrease in blood pressure from 140/90 to 110/70 indicates that the client has hypovolemia from loss of body fluid (in this case, blood).

Question 10 of 22 A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What health problem does the nurse suspect may be occurring? A) West Nile virus B) Stroke C) Meningitis D) Classic migraine

D) Classic migraine The nurse suspects that a classic migraine could be present when an ED client complains of frontal-temporal pain preceded by a visual disturbance. These symptoms are most typical of a classic migraine. Meningitis may present with a headache and visual disturbance but is usually accompanied by nuchal rigidity (neck stiffness) and fever. The symptoms of stroke will vary depending upon the area affected. Mild cases of West Nile virus may be asymptomatic or present with flulike symptoms, whereas severe cases may lead to loss of consciousness and death.

The RN working on an oncology unit has just received report on these clients. Which client will the nurse assess first? A) Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy. B) Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour. C) Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast. D) Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature.

D) Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature. The nurse should see the client with chemotherapy-induced neutropenia first. Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.

Question 5 of 20 The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A) Cardiovascular assessment B) Abdominal assessment, including bowel sounds C) Respiratory assessment D) Cognitive and neurologic assessment

D) Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs).

Question 12 of 22 A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What would the nurse do first? A) Administer phenytoin. B) Draw the client's blood. C) Start an intravenous (IV) line. D) Establish an airway.

D) Establish an airway. When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure. Phenytoin is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

Question 9 of 15 The nurse is recovering a client who had an esophagogastroduodenoscopy (EGD). What assessment would the nurse perform before determining if the client can have fluids to drink? A) Bowel sounds B) Orientation C) Presence of bruit D) Gag reflex

D) Gag reflex The nurse would check for the return of the client's gag reflex before allowing the client to drink or eat to prevent aspiration.

Question 15 of 20 The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A) Acute kidney injury B) Hypertension C) Pulmonary edema D) Infection

D) Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

Question 12 of 21 A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? A) Ensure that weights are placed on the floor. B) Remove the traction weights only for bathing. C) Ensure that pins are not loose and tighten as needed. D) Inspect the skin at least every 8 hours.

D) Inspect the skin at least every 8 hours. The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

Question 5 of 14 A client has recently developed acute sialadenitis (salivary gland infection ). Which intervention does the nurse include in this client's care? A) Request a prescription for an opioid to manage pain. B) Restrict fluids. C) Apply cold compresses. D) Massage the salivary gland.

D) Massage the salivary gland. Sialadenitis is inflammation of a salivary gland. The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening. To promote the flow of saliva, warm (not cold) compresses are applied to the affected salivary gland. Pain from this condition is managed with NSAIDs, not opioids. Hydration promotes salivary flow.

Question 10 of 14 A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A) High fat B) High fiber C) Carbohydrates D) Protein

D) Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with highfat content, and food with high-fiber content.

Question 3 of 16 An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention helps the client to increase protein intake? A) Keeping a food and fluid intake diary for at least 3 days B) Administering the liquid supplement with routine medications C) Giving a glucose polymer modular supplement D) Providing protein modular supplements in the form of puddings

D) Providing protein modular supplements in the form of puddings To increase the client's protein intake is to provide protein modular supplements in the form of puddings. This would increase the client's protein intake in a format other than a liquid supplement. Administering the liquid supplement with routine medications will not be effective because the client has already refused to drink the supplements. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. A food and fluid diary will provide information about the client's typical intake pattern, but will not increase protein intake.

Question 10 of 18 Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury? A) Special pressure-relief devices B) Frequent ambulation C) Encouraging nutrition D) Regular turning and repositioning

D) Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

NCLEX® Examination - Chapter 47 Question 1 of 21 The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? A) Affected foot slightly cooler than the other foot. B) Reports pain level is 4 on a 0-10 pain intensity scale. C) Pedal pulse on affected foot is 1+ and regular. D) Reports tingling and numbness in affected foot.

D) Reports tingling and numbness in affected foot. This client is at risk for neurovascular compromise or compartment syndrome from the external dressing. Pain and a slightly cooler foot is to be expected. However, the client should not have tingling and numbness suggesting that arterial blood flow is diminished.

Question 3 of 20 How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A) Obtains a walker for the client. B) Rearranges furniture to declutter the home. C) Removes throw rugs to prevent falls. D) Requests a bedside commode for the client.

D) Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

Question 6 of 20 The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A) Calcium B) Potassium C) Magnesium D) Sodium

D) Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

Question 14 of 21 The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? A) Prone for the first 1 to 2 hours B) High-Fowler for the first hour C) Side-lying for the first 2 hours D) Flat supine for the first 1 to 2 hours

D)Flat supine for the first 1 to 2 hours The flat supine position provides support for the percutaneous or minimally invasive surgical procedure.

Question 18 of 22 The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse? A) Severe unrelenting headaches B) Photophobia during the day C) Periodic nystagmus D) Decreased level of consciousness

Decreased level of consciousness Unlike the other assessment findings, decreased level of consciousness is life threatening and would be of greatest concern to the nurse.

Question 2 of 18 To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? A) Nutritional therapy B) Physical therapy C) Respiratory therapy D) Occupational therapy

c) Respiratory therapy To help prevent death for a client with spinal cord injury, collaboration with the respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with respiratory therapy is crucial. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.