Exam 4 - Med-Surg Success Questions; Breast Disorders, Endocrine & Some GI

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1. Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease. 2. The client has too much cortisol; this client should not be receiving prednisone, a steroid medication. 3. These are symptoms of hypoglycemia, which is not expected in this client because this client has high glucose levels. 4. The client is predisposed to osteoporosis and fractures. Contact sports should be avoided. TEST-TAKING HINT: If the test taker is not aware of the disease problem, this question could be answered correctly because of common standard discharge instructions—namely, notify the health-care provider of a fever.

The nurse is preparing to administer the following medications. Which medication should the nurse question administering? 1. The thyroid hormone to the client who does not have a T3, T4 level. 2. The regular insulin to the client with a blood glucose level of 210 mg/dL. 3. The loop diuretic to the client with a potassium level of 3.3 mEq/L. 4. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.

1. The thyroid hormone must be administered daily, and thyroid levels are drawn every six (6) months or so. 2. A blood glucose level of 210 mg/dL requires insulin administration; therefore, the nurse should not question administering this medication 3. This potassium level is below normal, which is 3.5 to 5.5 mEq/L. Therefore, the nurse should question administering this medication because loop diuretics cause potassium loss in the urine. 4. The digoxin level is within therapeutic range—0.8 to 2.0 mg/dL; therefore, the nurse should administer this medication. TEST-TAKING HINT: When administering medication, the nurse must know when to question the medication, how to know it is effective, and what must be taught to keep the client safe while taking the medication. The test taker may want to turn the question around and say, "I should give this medication."

The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

ANSWER: 1. Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland. 2. The client will have decreased fluid volume, and fluid restriction exacerbates a crisis. 3. The client requires a quiet, calm, relaxed atmosphere. 4. The client walks with a stooped posture from fatigue, but gait training is not needed. TEST-TAKING HINT: To answer this question, the test taker must have knowledge of adrenal gland function.

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

ANSWER: 1. The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation. 2. Stools are liquid or semiformed and usually do not contain blood. 3. Episodes of diarrhea and constipation may be a sign/symptom of colon cancer, not Crohn's disease. 4. A fever and hard rigid abdomen are signs/ symptoms of peritonitis, a complication of Crohn's disease. TEST-TAKING HINT: The test taker should eliminate option "2" because of the word "all," which is an absolute. There are very few absolutes in the health-care arena.

The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.

ANSWER: 1. A decrease in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss. 2. These are signs of hyperthyroidism. 3. These are signs of hyperthyroidism. 4. These are signs of parathyroidism. TEST-TAKING HINT: Often if the test taker does not know the specific signs/symptoms of the disease, but knows the function of the system affected by the disease, some possible answers can be ruled out. Tetany and stiffness of the hands are related to calcium, the level of which is influenced by the parathyroid gland, not the thyroid gland; therefore, option "4" can be ruled out.

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

ANSWER: 1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon. 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon include increasing age; family history of colon cancer or polyps; history of IBD; genital or breast cancer; and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females. TEST-TAKING HINT: The test taker should realize cancers in general have an increasing incidence with age. Cancer etiologies are not an exact science, but most cancers have some risk factor, if only advancing age.

6. Which laboratory data make the nurse suspect the client with primary hyperparathyroidism is experiencing a complication? 1. A serum creatinine level of 2.8 mg/dL. 2. A calcium level of 9.2 mg/dL. 3. A serum triglyceride level of 130 mg/dL. 4. A sodium level of 135 mEq/L.

ANSWER: 1. A serum creatinine level of 2.8 mg/dL indicates the client is in renal failure, which is a complication of hyperparathyroidism. The formation of stones in the kidneys related to the increased urinary excretion of calcium and phosphorus occurs in about 55% of clients with primary hyperparathyroidism and can lead to renal failure. 2. This calcium level is within the normal range of 9.0 to 10.5 mg/dL. 3. This serum triglyceride level is within the normal range of 40 to 150 mg/dL in males and 30 to 140 mg/dL for females. 4. This sodium level is within the normal range of 135 to 145 mEq/L.

The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.

ANSWER: 1. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low sodium level. 2. This is a normal potassium level, and a heightened level of awareness indicates drug usage. 3. This is a normal calcium level and the client is fluid overloaded, not dehydrated, so there would not be tented tissue turgor. 4. This is a normal magnesium level, and a large urinary output is desired. TEST-TAKING HINT: The nurse must know common laboratory values.

4. Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)? 1. An enlarged forehead, maxilla, and face. 2. A six (6)-inch increase in height of the client. 3. The client complaining of a severe headache. 4. A systolic blood pressure of 200 to 300 mm Hg.

ANSWER: 1. Acromegaly (enlarged extremities) occurs when sustained GH hypersecretion begins during adulthood, most commonly because of a pituitary tumor. 2. Gigantism occurs when GH hypersecretion begins before puberty when the closure of the epiphyseal plates occurs. Note the age of the client. 3. A severe headache is not a symptom of acromegaly. 4. High blood pressure is a sign of pheochromocytoma.

The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership? 1. Call a meeting and educate the staff on the new delivery system being used. 2. Organize a committee to investigate the various types of delivery systems. 3. Wait until another unit has implemented the new system and see if it works out. 4. Discuss with the nursing staff if a new delivery system should be adopted.

ANSWER: 1. An autocratic style is one in which the person in charge makes the decision without consulting anyone else. 2. This behavior is an example of a democratic leadership style. 3. This behavior is an example of laissez-faire leadership style. 4. This behavior is an example of democratic leadership style. TEST-TAKING HINT: The test taker could choose the correct answer if the test taker knew terms such as "autocratic" and "democratic."

The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.

ANSWER: 1. External heat sources (heating pads, electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse. 2. Assessing the client's temperature every two (2) hours is not needed because the temperature will not change quickly. The client needs thyroid hormones to help increase the client's temperature. 3. The room temperature should be kept warm because the client will have complaints of being cold. 4. The client is fatigued and this is an appropriate intervention, but is not applicable to the client problem of "risk for imbalanced body temperature." TEST-TAKING HINT: The test taker must always know exactly what the question is asking. Option "4" can be ruled out because it does not address body temperature. If the test taker knows the normal function of the thyroid gland, this may help identify the answer; decreased metabolism will cause the client to be cold.

The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? 1. Explain it will take up to a month for symptoms of hyperthyroidism to subside. 2. Teach the iodine therapy will have to be tapered slowly over one (1) week. 3. Discuss the client will have to be hospitalized during the radioactive therapy. 4. Inform the client after therapy the client will not have to take any medication.

ANSWER: 1. Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached. 2. A single dose of radioactive iodine therapy is administered; the dosage is based on the client's weight. 3. The colorless, tasteless radioiodine is administered by the radiologist, and the client may have to stay up to two (2) hours after the treatment in the office. 4. If too much of the thyroid gland is destroyed by the radioactive iodine therapy, the client may develop hypothyroidism and have to take thyroid hormone the rest of his or her life. TEST-TAKING HINT: Some questions require the test taker to be knowledgeable of the information, especially medical treatments, and there are no specific hints to help the test taker answer the question.

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

ANSWER: 1. The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary. 2. Sitting in the waiting area could cause the client to go into a coma and die. 3. A blood transfusion is not an appropriate intervention for this client. 4. Laboratory specimens are not priority and calcium is not a problem in clients with Addison's disease. TEST-TAKING HINT: This client is weak, lethargic, and forgetful, indicating a diminished level of consciousness. The nurse should choose an action addressing the problem.

Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells

ANSWER: 1. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes insipidus is a totally separate disease process. 2. Serum calcium is not affected by diabetes insipidus. 3. Urine glucose is monitored for diabetes mellitus. 4. White blood cells in the urine indicate the presence of a urinary tract infection. TEST-TAKING HINT: The test taker should not confuse diabetes insipidus and diabetes mellitus.

The client with ulcerative colitis is scheduled for an ileostomy. The nurse is aware the client's stoma will be located in which area of the abdomen? 1. RLQ 2. LLQ 3. Epigastric area 4. RUQ

ANSWER: 1. The cure for ulcerative colitis is a total colectomy, which is removing the entire large colon and bringing the terminal end of the ileum up to the abdomen in the right lower quadrant. This is an ileostomy. 2. This site is the left-lower quadrant 3. This site is the transverse colon. 4. This site is the right upper quadrant. TEST-TAKING HINT: The test taker must identify the area by using the computer mouse. These are called "hot spots" on the NCLEX-RN.

12. The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement? 1. Check the posterior neck for bleeding. 2. Assess the client for the Chvostek's sign. 3. Monitor the client's serum calcium level. 4. Change the client's surgical dressing.

ANSWER: 1. The incision for a thyroidectomy allows the blood to drain dependently by gravity to the back of the client's neck. Therefore, the nurse should check this area for hemorrhaging, which is a possible complication of any surgery. 2. The Chvostek's sign indicates hypocalcemia, which is too early to assess for in this client. 3. Accidental removal of or damage to the parathyroid glands will not decrease the calcium level for at least 24 hours. 4. Surgeons prefer to change the surgical dressing for the first time.

The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

ANSWER: 1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening. 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assessment is completed. TEST-TAKING HINT: The question is asking the test taker to determine which intervention must be implemented first, and assessment is the first step of the nursing process. Options "2," "3," and "4" would not be implemented prior to assessing. Marking the dressing allows the nurse to assess the dressing and determine if active bleeding is occurring.

The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.

ANSWER: 2. A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a PaO2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention. 1. Hypoglycemia is expected in a client with myxedema; therefore, a 74-mg/dL blood glucose level is expected. 3. The client with myxedema coma is in an exaggerated hypothyroid state; a low pulse is expected in a client with hypothyroidism. 4. Lethargy is an expected symptom in a client diagnosed with myxedema; therefore, this does not warrant immediate intervention. TEST-TAKING HINT: The words "warrant immediate intervention" means the test taker should select an option which is abnormal for the disease process or a life-threatening symptom.

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

ANSWER: 2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon. 1. Some cancers have a higher risk of development when the client is occupationally exposed to chemicals, but cancer of the colon is not one of them. 3. A multiple vitamin may improve immune system function, but it does not prevent colon cancer. 4. High-risk sexual behavior places the client at risk for sexually transmitted diseases. A history of multiple sexual partners and initial sexual experience at an early age does increase the risk for the development of cancer of the cervix in females. TEST-TAKING HINT: The colon processes waste products from eating foods, and option "2" is the only option to mention food. Therefore, option "2" would be the best option to select if the test taker did not know the correct answer.

21. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison's disease? 1. Discuss the importance of tapering medications when discontinuing medication. 2. Explain the dose may need to be increased during times of stress or infection. 3. Instruct the client to take medication on an empty stomach with a glass of water. 4. Encourage the client to wear clean white socks when wearing tennis shoes.

ANSWER: 2. During times of stress, the medication may need to be increased to prevent adrenal insufficiency. 1. The client will have to receive this medication the rest of his or her life, so this should not be discussed with the client. 3. The medication should be taken with food to minimize its ulcerogenic effect. 4. Wearing white socks with tennis shoes is not an intervention pertinent to a client diagnosed with Addison's disease.

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

ANSWER: 2. Early signs and symptoms are nausea and vomiting. The client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. In other words, the client is producing a hormone that will not allow the client to urinate. 1. The client has excess fluid and is not dehydrated, and blood glucose levels are not affected. 3. The client experiences dilutional hyponatremia, and the body has too much fluid already. 4. Vasopressin is the name of the antidiuretic hormone. Giving more increases the client's problem. Also, a water challenge test is performed, not a fluid deprivation test. TEST-TAKING HINT: The syndrome's name is confusing, with a double negative— "inappropriate" and "anti." It is helpful to put the situation in the test taker's own words to remember which way the fluids are being shifted in the body.

Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.

ANSWER: 2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism. 1. These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation. 3. Decreased blood pressure and slow heart rate are signs of myxedema coma. 4. These are signs/symptoms of myxedema coma. TEST-TAKING HINT: If the test taker does not have the knowledge to answer the question, the test taker should look at the options closely. Options "1," "3," and "4" all have signs/symptoms of "decrease"— hypoactive, hypotension, and hypoxia. The test taker should select the option which does not match.

The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."

ANSWER: 2. Medication for DI is usually taken every 8 to 12 hours, depending on the client. The client should keep the medication close at hand. 1. The client should keep a list of medication being taken and wear a Medic Alert bracelet. 3. The client is at risk for fluid shifts. Weighing every morning allows the client to follow the fluid shifts. Weight gain indicates too much medication. 4. Tightness in the chest could be an indicator the medication is not being tolerated; if this occurs, the client should notify the health-care provider. TEST-TAKING HINT: This is an "except" question. This means all answers except one will be actions the client should do. If the test taker missed interpreting this from the stem, then the test taker could jump to the first action the client should do as the correct answer.

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells.

ANSWER: 2. The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol. 1. The drugs quinidine, digoxin, and hydralazine can interfere with adrenal gland secretions and cause hypofunction. Cushing's syndrome is adrenal gland hyperfunction. 3. A 24-hour urine specimen for 17-hydroxycorticosterone and 17-ketosteroid may be collected. Metanephrines and catecholamines are urine collections for pheochromocytomas. 4. Spot urinalysis and white blood cell count will not provide information on adrenal gland functions. TEST-TAKING HINT: If the test taker is aware the adrenal gland produces cortisol, then there is only one answer option which refers to cortisol.

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."

ANSWER: 2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client's statement indicates the need for further teaching. 1. If the tissue around the stoma becomes excoriated, the client will be unable to pouch the stoma adequately, resulting in discomfort and leakage. The client understands the teaching. 3. Until the incision is completely healed, the client should not sit in bath water because of the potential contamination of the wound by the bath water. The client understands the teaching. 4. The client has had major surgery and should limit lifting to minimal weight. The client understands the teaching. TEST-TAKING HINT: This is an abdominal surgery and all instructions for major surgery apply. This is an "except" question; therefore, three (3) options would indicate the client understands the teaching.

9. Which psychosocial problem should be included in the plan of care for a female client diagnosed with Cushing's syndrome? 1. Altered glucose metabolism. 2. Body image disturbance. 3. Risk for suicide. 4. Impaired wound healing.

ANSWER: 2. The client with Cushing's syndrome has body changes, including moon face, buffalo hump, truncal obesity, hirsutism, and striae and bruising, all of which affect the client's body image. 1. This is not a psychosocial problem; it is a physiological problem in clients diagnosed with Cushing's syndrome. 3. This is a psychosocial problem, but it is not one which commonly occurs in clients diagnosed with Cushing's syndrome. 4. This is not a psychosocial problem; it is a physiological problem which does occur in clients diagnosed with Cushing's syndrome.

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

ANSWER: 2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate. 1. The nurse should first assess the situation prior to informing the HCP of the client's concerns and then allow the HCP and client to discuss the situation. 3. If a new HCP is to be arranged, it is the HCP's responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client's. If the HCP cannot arrange for another HCP, the client may be discharged and obtain a new health-care provider. TEST-TAKING HINT: The nurse should assess the situation; the first step in the nursing process is assessment.

The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.

ANSWER: 2. The output is more than double the intake in a short time. This client could be developing diabetes insipidus, a complication of trauma to the head. 1. Neurological status is monitored every one (1) to two (2) hours. This client's neurological status appears intact. Clients waking up in an intensive care area may not be aware of their surroundings. 3. These vital signs are within normal limits. 4. A transsphenoidal hypophysectomy is performed by surgical access above the gum line and through the nasal passage. There is no dressing. A drip pad is taped below the nares. TEST-TAKING HINT: Two (2) of the answer options contain normal data and would not warrant immediate intervention. Option "4" does not match the type of surgery.

20. Which question should the nurse ask when assessing the client for an endocrine dysfunction? 1. "Have you noticed any pain in your legs when walking?" 2. "Have you had any unexplained weight loss?" 3. "Have you noticed any change in your bowel movements?" 4. "Have you experienced any joint pain or discomfort?"

ANSWER: 2. Weight loss with normal appetite may indicate hyperthyroidism. 1. Leg pain when walking indicates intermittent claudication, which occurs with peripheral vascular disease. 3. Changes in bowel movements may indicate colon cancer. 4. Joint pain indicates a musculoskeletal or degenerative joint disease.

5. Which sign/symptom indicates to the nurse the client is experiencing hyperparathyroidism? 1. A negative Trousseau's sign. 2. A positive Chvostek's sign. 3. Nocturnal muscle cramps. 4. Tented skin turgor.

ANSWER: 2. When a sharp tapping over the facial nerve elicits a spasm or twitching of the mouth, nose, or eyes, the client is hypocalcemic, which occurs in clients with hyperparathyroidism. This is known as a positive Chvostek's sign. 1. A carpopedal spasm occurs when the blood flow to the arm is decreased for three (3) minutes with a blood pressure cuff; a positive Trousseau's sign indicates hypocalcemia, which is a sign of hyperparathyroidism. 3. Muscle cramps makes the nurse suspect hypokalemia (low potassium). 4. Tented skin turgor makes the nurse suspect dehydration, which occurs with hypernatremia.

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

ANSWER: 3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended. 1. Fried potatoes, along with pastries and pies, should be avoided. 2. Raw vegetables should be avoided because this is roughage. 4. Fried foods should be avoided, and whole grain is high in fiber. Nuts and fruits with peels should be avoided. TEST-TAKING HINT: The test taker must know about therapeutic diets prescribed by health-care providers. Remember, low-residue is the same as low-fiber.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

ANSWER: 3. Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face. 1. Blood glucose levels do not address the problem of altered body image. 2. Head-to-toe assessments are performed to detect a physiological problem, not a psychosocial one. 4. Bowel sounds and temperature are physical symptoms. TEST-TAKING HINT: The intervention must match the problem.

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

ANSWER: 3. Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease. 1. A moon face, buffalo hump, and hyperglycemia result from Cushing's syndrome, hyperfunction of the adrenal gland. 2. Hirsutism is hair growth where it normally does not occur, such as facial hair on women. Fever and irritability, along with hirsutism, are clinical manifestations of Cushing's syndrome. 4. Tachycardia, bulging eyes, and goiter are clinical manifestations occurring with thyroid disorders. TEST-TAKING HINT: This question contains answer options referring to opposite diseases, Addison's disease and Cushing's syndrome. If two options—in this case, options "1" and "2"—are appropriate for one of the diseases, then these two can be ruled out as the correct answer.

11. Which client history is most significant in the development of symptoms for a client who has iatrogenic Cushing's disease? 1. Long-term use of anabolic steroids. 2. Extended use of inhaled steroids for asthma. 3. History of long-term glucocorticoid use. 4. Family history of increased cortisol production.

ANSWER: 3. Iatrogenic Cushing's disease is Cushing's disease caused by medical treatment—in this case, by taking excessive steroids resulting in the symptoms of moon face, buffalo hump, and other associated symptoms. 1. Anabolic steroids are used by individuals to build muscle mass. Long-term use can lead to psychosis or heart attacks. 2. Inhaled steroids do not have systemic effects, which is described by iatrogenic Cushing's disease. 4. Family history does not cause iatrogenic problems.

13. Which signs/symptoms indicate the client with hypothyroidism is not taking enough thyroid hormone? 1. Complaints of weight loss and fine tremors. 2. Complaints of excessive thirst and urination. 3. Complaints of constipation and being cold. 4. Complaints of delayed wound healing and belching.

ANSWER: 3. If the client were not taking enough thyroid hormone, the client would exhibit symptoms of hypothyroidism such as constipation and being cold. 1. Weight loss and fine tremors make the nurse suspect the client is taking too much thyroid hormone because these are symptoms of hyperthyroidism. 2. Excessive thirst and urination are symptoms of diabetes. 4. This indicates Cushing's disease.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.

ANSWER: 3. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize. 1. Clients with SIADH have a problem with retaining fluid. This is expected. 2. This client's intake and output are relatively the same. 4. The client has to get up all night to urinate, so the client feeling tired is expected. TEST-TAKING HINT: All of the answer options contain expected information except option "3."

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every (2) hours.

ANSWER: 3. Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge. 1. A unilateral adrenalectomy results in one adrenal gland still functioning. No hormone replacement will be required. 2. The client can still have normal physiological functioning, including sexual functioning, with the remaining gland. 4. Turning and coughing is taught prior to surgery, not at discharge. TEST-TAKING HINT: The test taker must notice the adjectives; "discharge" tells the reader a time frame for the instructions. This rules out option "4."

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

ANSWER: 3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years. 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. "Middle age" is a relative term; specific ages are used for recommendation. 4. A flexible sigmoidoscopy should be done at five (5)-year intervals between the colonoscopy. TEST-TAKING HINT: A digital examination is an examination performed by the examiner's finger and does not examine the entire colon.

19. The nurse is discussing the endocrine system with the client. Which endocrine gland secretes epinephrine and norepinephrine? 1. The pancreas. 2. The adrenal cortex. 3. The adrenal medulla. 4. The anterior pituitary gland.

ANSWER: 3. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. 1. The endocrine function of the pancreas is the secretion of insulin and amylin. 2. The adrenal cortex secretes mineralocorticoids, glucocorticoids, and gonadotrophins. 4. The anterior pituitary gland secretes the growth hormone.

The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be administered an injection of antidiuretic hormone, and urine output will be measured for four (4) to six (6) hours. 3. The client will be NPO, and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.

ANSWER: 3. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated. 1. The client is not allowed to drink during the test. 2. This test does not require any medications to be administered, and vasopressin will treat the DI, not help diagnose it. 4. No fluid is allowed and a sonogram is not involved. TEST-TAKING HINT: The name of the test is a fluid deprivation test. Two (2) of the options require the administration of some type of fluid.

The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis.

ANSWER: 3. The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective. 1. The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state. 2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective. 4. Diaphoresis (sweating) occurs with hyperthyroidism, not hypothyroidism. TEST-TAKING HINT: One way of determining the effectiveness of medication is to determine if the signs/symptoms of the disease are no longer noticeable.

The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I & O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.

ANSWER: 3. The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma. 1. The client should have the water pitcher filled, but this is not the first action. 2. This should be done but not before assessing the problem. 4. This could be done, but it will not give the nurse information about DI. TEST-TAKING HINT: The nurse must apply a systematic approach to answering priority questions. Maslow's hierarchy of needs should be applied if it is a physiological problem and the nursing process if it is a question of this nature. Assessment is the first step in the nursing process.

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.

ANSWER: 3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation. 1. Frequent bloody stools are a symptom of inflammatory bowel disease (IBD). IBD is a risk factor for cancer of the colon, but the symptoms are different when the colon becomes cancerous. 2. Most people have a feeling of fullness after a heavy meal; this does not indicate cancer. 4. Lower right quadrant pain with rebound tenderness would indicate appendicitis. TEST-TAKING HINT: The test taker could eliminate option "4" based on anatomical position. The rectosigmoid colon is in the left lower quadrant.

7. The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma? 1. A history of skin cancer. 2. A history of high blood pressure. 3. A family history of adrenal tumors. 4. A family history of migraine headaches.

ANSWER: 3. There is a high incidence of pheochromocytomas in family members with adrenal tumors, and the von Hippel-Lindau gene is thought to be a primary cause. 1. A history of skin cancer is not a risk factor for pheochromocytoma. 2. A history of high blood pressure is a sign of this disease, not a risk factor for developing it. 4. Headaches are a symptom of this disease but not a risk factor for it.

The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.

ANSWER: 3. This client has a low blood pressure and tachycardia. This client may be experiencing an addisonian crisis, a potentially life-threatening condition. The most experienced nurse should care for this client. 1. This client could be cared for by any nurse qualified to work in an intensive care unit. 2. These blood gases are within normal limits. 4. A negative Trousseau's sign is normal for this client. TEST-TAKING HINT: The answer options "1," "2," and "4" have expected or normal data. Only one option has abnormal data. Even if the test taker is unaware of addisonian crisis, these are vital signs indicating potential shock.

The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.

ANSWER: 3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency. 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client who has an intestinal blockage will need to be hydrated. 4. Tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. The client can expel this water. TEST-TAKING HINT: The stem states a "complete blockage," which indicates the client needs surgery. Therefore, options "1" and "2" are appropriate for surgery. The stem asks the test taker which order would be questioned, so this is an "except" question.

The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.

ANSWER: 3. This is an example of autonomy (the client has the right to decide for himself). 1. Discussing the information with others is not allowing the client to decide what is best for himself. 2. This could be an example of beneficence (to do good) if the nurse did this so the client has information on which to base a decision on whether to continue the fluid restriction. 4. This is an example of dishonesty and should never be tolerated in a health-care setting. TEST-TAKING HINT: The stem asks the test taker about autonomy. Even if the test taker did not know the ethical principle, autonomy means the right of self-governance. Only one of the answer options could fit the definition of autonomy.

Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? 1. Thyroid hormones. 2. Oxygen. 3. Sedatives. 4. Laxatives.

ANSWER: 3. Untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication. 1. Thyroid hormones are the treatment of choice for the client diagnosed with hypothyroidism; therefore, the nurse should not question this medication. 2. In untreated hypothyroidism, the medical management is aimed at supporting vital functions, so administering oxygen is an appropriate medication. 4. Clients with hypothyroidism become constipated as a result of decreased metabolism, so laxatives should not be questioned by the nurse. TEST-TAKING HINT: When a question asks which order the nurse should question, three of the options are medications the nurse expects to administer to the client. Sometimes saying, "The nurse administers this medication," may help the test taker select the correct answer.

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

ANSWER: 4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow. 1. Intimacy involves more than sexual intercourse. The client can be sexually active whenever the wounds are healed sufficiently to not cause pain. 2. This is an appropriate nursing intervention for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor who would have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvantages of sexual positioning. TEST-TAKING HINT: Option "2" does not address the issue and option "3" is outside of the nurse's professional expertise. Option "1" could be eliminated because of the word "no," which is an absolute word.

The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response? 1. "It is because of the screening techniques used in the United States." 2. "It is a genetic predisposition rare in North Americans." 3. "The medications available in the United States decrease goiters." 4. "Iodized salt helps prevent the development of goiters in the United States."

ANSWER: 4. Almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, which is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the United States has iodine added. 1. There is no screening for thyroid disorders, just serum thyroid levels. 2. This is not a true statement. 3. Medications do not decrease the development of goiters. TEST-TAKING HINT: The nurse must know about disease processes. There is no Test-Taking Hint to help with knowledge.

8. The client is three (3) days postoperative unilateral adrenalectomy. Which discharge instructions should the nurse teach? 1. Discuss the need for lifelong steroid replacement. 2. Instruct the client on administration of vasopressin. 3. Teach the client to care for the suprapubic Foley catheter. 4. Tell the client to notify the HCP if the incision is inflamed.

ANSWER: 4. Any inflammation of the incision indicates an infection and the client will need to receive antibiotics, so the HCP must be notified. 1. Because the client has one adrenal gland remaining, the client may not need lifelong supplemental steroids. 2. Vasopressin is administered to clients with diabetes insipidus. 3. The client does not have a suprapubic catheter during this procedure.

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

ANSWER: 4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process. 1. Asulfidine cannot be administered rectally. Corticosteroids may be administered by enema for the local effect of decreasing inflammation while minimizing the systemic effects. 2. Antidiarrheal agents slow the gastrointestinal motility and reduce diarrhea. 3. IBD is not caused by bacteria. TEST-TAKING HINT: If the test taker doesn't know the answer, then the test taker could eliminate options "2" and "3" because they do not contain the word "inflammation"; IBD is inflammatory bowel disease.

10. The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.

ANSWER: 4. Blood pressure is affected by aldosteronism, with hypertension being the most prominent and universal sign of aldosteronism. 1. The temperature is not affected by aldosteronism. 2. The pulse is not affected by this disorder. 3. The respirations are not affected by this disorder.

The client is two (2) hours post-colonoscopy. Which assessment data warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

ANSWER: 4. Bowel perforation is a potential complication of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse. 1. The client's abdomen should be soft and nontender; therefore, this finding would not require immediate intervention. 2. The client had to clean the bowel prior to the colonoscopy; therefore, watery stool is expected. 3. The client was NPO and received bowel preparation prior to the colonoscopy; therefore, hyperactive bowel sounds might occur and do not warrant immediate intervention. TEST-TAKING HINT: This is an "except" question. The test taker is being asked to select which data are abnormal for a procedure. The test taker should remember any invasive procedure could possibly lead to hemorrhaging, and signs of shock should always be considered a possible correct answer.

24. Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Excessive thirst. 2. Orthopnea. 3. Ascites. 4. Concentrated urine output.

ANSWER: 4. Excess antidiuretic hormone (ADH) causes SIADH, which causes increased water reabsorption and leads to increased fluid volume and scant, concentrated urine. 1. Excessive thirst is a symptom of diabetes insipidus, which is a deficiency of antidiuretic (ADH) hormone. 2. Orthopnea is difficulty breathing when in the supine position, which is not a sign/symptom of SIADH. 3. Ascites is excess fluid in the peritoneal cavity, which is not a sign/symptom of SIADH.

The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.

ANSWER: 4. Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia. 1. Altered body image is a psychosocial problem, which is not a priority over a potentially lethal physical complication, and physical changes occur over an extended period. 2. Activity intolerance will occur with adrenal gland hypofunction, but this is not a priority over dehydration. 3. Impaired coping can occur in clients with adrenal gland disorders, but it is not a priority over dehydration. TEST-TAKING HINT: Assuming all of the problems listed apply to the client diagnosed with Addison's disease, two are psychosocial problems and two are physiological. Applying Maslow's hierarchy of needs, the two psychological problems can be ruled out as the highest priority. Of the two options remaining, activity intolerance is not life altering or threatening.

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.

ANSWER: 4. The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently. 1. Diabetes insipidus is not diabetes mellitus; sliding-scale insulin is not administered to the client. 2. There is no caffeine restriction for DI. 3. Checking urine ketones is not indicated. TEST-TAKING HINT: Two (2) of the answer options are appropriate for diabetes mellitus, not diabetes insipidus, and can be eliminated on this basis alone.

The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.

ANSWERS: 1., 3., 5. 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 5. The client should not sit upright because this causes pressure on the perineum. 2. There are midline and perineal incisions, not flank incisions. 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. TEST-TAKING HINT: The test taker could eliminate option "2" because flank and abdominal-perineal are not in the same areas. This is an alternative-type question requiring the test taker to choose more than one (1) option.

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

ANSWER: 4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring. 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in normal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a "5." Delaying taking medication will delay the onset of pain relief and the client will not receive full benefit from the medication. TEST-TAKING HINT: Normal mucosa is pink, not white, and clients are always encouraged to ambulate after surgery to prevent the complications related to immobility. Remember basic concepts when answering questions, especially about postoperative nursing care.

Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? 1. "I just don't seem to have any appetite anymore." 2. "I have a bowel movement about every 3 to 4 days." 3. "My skin is really becoming dry and coarse." 4. "I have noticed all my collars are getting tighter."

ANSWER: 4. The thyroid gland (in the neck) enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter. 1. Decreased appetite is a symptom of hypothyroidism, not hyperthyroidism. 2. Constipation is a symptom of hypothyroidism. 3. Dry, coarse skin is a sign of hypothyroidism. TEST-TAKING HINT: If the test taker does not know the answer, sometimes thinking about the location of the gland or organ causing the problem may help the test taker select or rule out specific options.

The nurse is preparing to hang a new bag of total parental nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump? _________

ANSWER: 85 mL/hr. First determine the total amount to be infused over 24 hours: 1500 + 500 + 20 + 20 = 2,040 mL over 24 hours Then, determine the rate per hour: 2,040 ÷ 24 = 85 mL/hr TEST-TAKING HINT: Check and recheck calculations. Division should be carried out to the second or third decimal place before rounding.

The client diagnosed with Cushing's disease has developed 1+ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received IVPB medication in 50 mL of fluid every 6 hours for 15 doses. How many mL of fluid did the client receive? ________

ANSWER: The client has received 8,650 mL of intravenous fluid. TEST-TAKING HINT: This is a basic addition problem. If the test taker has difficulty with this problem, then a math review course would be in order.

The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time? ______

ANSWER: Two (2) sprays per dose. 40 g of medication every 24 hours is to be given in doses administered every 12 hours. First, determine number of doses needed: 24 ÷ 12 = 2 doses Then, determine the amount of medication to be given in each of those two (2) doses: 40 ÷ 2 = 20 g of medication per dose Finally, determine how many sprays are needed to deliver the 20 mg when each spray delivers 10 g: 20 ÷ 10 = 2 sprays

Which nursing intervention should be included in the plan of care of the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day.

ANSWER:4. The client with hyperthyroidism has an increased appetite; therefore, wellbalanced meals served several times throughout the day will help with the client's constant hunger. 1. Fiber should be increased in the client diagnosed with hypothyroidism because the client experiences constipation secondary to decreased metabolism. 2. The client with hyperthyroidism should have a high-calorie, high-protein diet. 3. The client's fluid intake should be increased to replace fluids lost through diarrhea and excessive sweating. TEST-TAKING HINT: If the test taker knows the metabolism is increased with hyperthyroidism, then increasing the food intake is the most appropriate choice.

The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. 1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication. 4. Carry a medical identification card or bracelet. 5. Teach how to take thyroid medications correctly.

ANSWERS: 1., 2., 3., 4. 1. Weight loss indicates the medication may not be effective and will probably need to be increased. 2. The client needs to know emotional highs and lows are secondary to hyperthyroidism. With treatment, this emotional lability will subside. 3. Any over-the-counter medications (for example, alcohol-based medications) may negatively affect the client's hyperthyroidism or medications being used for treatment. 4. This will help any HCP immediately know of the client's condition, especially if the client is unable to tell the HCP. 5. The client with hyperthyroidism will be on antithyroid medications, not thyroid medications. TEST-TAKING HINT: This alternate-type question instructs the test taker to select all the interventions which apply. The test taker must read and evaluate each option as to whether it applies or not.

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.

ANSWERS: 1., 2., 4. 1. Fluids are restricted to 500 to 600 mL per 24 hours. 2. Orientation to person, place, and time should be assessed every two (2) hours or more often. 4. Urine and serum osmolality are monitored to determine fluid volume status. 3. A safe environment, not a stimulating one, is provided. 5. The client should be weighed daily. TEST-TAKING HINT: The test taker should notice numbers: Is assessing the client's level of consciousness every two (2) hours enough, or is weighing the client every three (3) days enough?

The nurse is teaching a class on Breast Health Awareness. Which are the American Cancer Society's recommended guidelines for the performance of breast selfexamination (BSE)? List in order of recommended performance. 1. Visualize the breast from the front while standing before a mirror. 2. Gently squeeze the nipple to express any fluid. 3. Turn to each side and view each breast in the mirror. 4. Palpate each breast in a circular motion while lying on the back. 5. Palpate each breast in a circular motion while in the shower.

Answer: 1, 3, 5, 4, 2. 1. The first step in BSE is to visualize the breasts for symmetry while looking at a frontal view before the mirror. 3. The next step is to turn from side to side, looking for any dimpling, puckering, or asymmetry, in front of a mirror. 5. The client should palpate the breasts in a warm shower with the breasts soaped to allow for the fingers to glide over the breast tissue. 4. After the shower, the client should lie on the bed with a towel rolled up and placed under the shoulder to flatten the breast tissue and palpate the breast. 2. The last step in BSE is to gently squeeze the nipple to determine if there is expressed fluid.

The client who is scheduled to have a breast biopsy with sentinel node dissection states, "I don't understand. What does a sentinel node biopsy do?" Which scientific rationale should the nurse use to base the response? 1. A dye is injected into the tumor and traced to determine spread of cells. 2. The surgeon removes the nodes that drain the diseased portion of the breast. 3. The nodes felt manually will be removed and sent to pathology. 4. A visual inspection of the lymph nodes will be made while the client is sleeping.

Answer: 1. A sentinel node biopsy is a procedure in which a radioactive dye is injected into the tumor and then traced by instrumentation and color to try to identify the exact lymph nodes the tumor could have shed into. 2. This is the older procedure in which the surgeon removed the nodes thought to drain the tumor. There was no way of knowing if the surgeon was actually removing the affected nodes. 3. The purpose of the procedure is not to rely on guesswork in determining the extent of tumor involvement. 4. Microscopic disease cannot be seen by the naked eye. TEST-TAKING HINT: The test taker could eliminate options "3" and "4" if he or she were aware of the definition of sentinel, which means "to watch over as a sentry." This might lead the test taker to determine that specific areas would have to be identified.

The client has a diagnosis of rule-out Paget's disease. Which test provides a definitive diagnosis of the disease? 1. A breast biopsy. 2. A diagnostic mammogram. 3. Ultrasound of the breast. 4. Magnetic resonance imaging.

Answer: 1. Biopsy of the lesion is the only definitive test for Paget's disease, a form of breast cancer accounting for about 1% of all breast cancers. 2. Mammography is the only test that routinely screens for breast cancer, but a definitive diagnosis is made by tissue identification. 3. Ultrasound of the breasts can diagnose fluid-filled cysts. 4. Magnetic resonance imaging can be done to determine the extent of tumor involvement, but tissue identification is the definitive test for tumor diagnosis.

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.

Answer: 1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely. 2. The client may be on sliding-scale regular insulin coverage for the high glucose level. 3. The TPN must be administered via a subclavian line because of the high glucose level. 4. The client is NPO to put the bowel at rest, which is the rationale for administering the TPN. TEST-TAKING HINT: The test taker may want to select option "3" because it has the word "assess," but the test taker should remember to note the adjective "peripheral," which takes this option incorrect. Remember, the words "check" and "monitor" are words meaning "assess."

The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach? 1. Don't lift more than five (5) pounds with the left hand until released by the HCP. 2. The cancer has been totally removed and no follow-up therapy will be required. 3. The client should empty the Hemovac drain about every 12 hours. 4. The client should arrange an appointment with a plastic surgeon for reconstruction.

Answer: 1. The client has had surgery on this side of the body. Pressure on the incision should be limited until the client is released by the HCP to perform normal daily activities. 2. This is providing the client false hope. Cancer cells characteristically move easily in the lymph or bloodstream to other parts of the body. Microscopic disease cannot be determined by the naked eye. 3. A client who has a mastectomy might be discharged with a Hemovac drain, but a wedge resection should not require one. 4. The breast has not been removed; reconstruction is not needed. TEST-TAKING HINT: If the test taker did not know this answer, option "1" is information provided to any client who has had surgery on the upper chest or arm.

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence.

Answer: 1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis. 2. Inflammation usually causes an elevated temperature but is not expected in the client with ulcerative colitis. 3. A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis but not an expected symptom. 4. Stress incontinence is not a symptom of colitis. TEST-TAKING HINT: If the test taker is not sure of the answer, the test taker should use knowledge of anatomy and physiology to help identify the correct answer. The colon is responsible for absorbing water, and if the colon can't do its job, then water will not be absorbed, causing diarrhea (option "1"). Colitis is inflammation of the colon; therefore, option "4" referring to the urinary system can be eliminated.

The client who has had a mastectomy tells the nurse, "My husband will leave me now since I am not a whole woman anymore." Which response by the nurse is most therapeutic? 1. "You're afraid your husband will not find you sexually appealing?" 2. "Your husband should be grateful you will be able to live and be with him." 3. "Maybe your husband would like to attend a support group for spouses." 4. "You don't know that is true. You need to give him a chance."

Answer: 1. This is restating the client's feelings and is a therapeutic response. 2. This is not recognizing the client's concerns and putting the nurse's expectations on the spouse. 3. This is problem-solving and could be offered, but the therapeutic response is to restate the client's feeling and encourage a conversation. 4. The client may know this is true. The nurse is telling the client she has no reason for her feelings. Feelings are what they are and should be accepted as such. TEST-TAKING HINT: When the question asks for a therapeutic response, the test taker should choose an option encouraging the client to ventilate her feelings.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.

Answer: 2. "Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis. 1. Cushing's disease is not an autoimmune problem. 3. This could be a cause for primary Cushing's syndrome. 4. There is a known reason for the client to have iatrogenic Cushing's syndrome. TEST-TAKING HINT: This question requires the test taker to know basic medical terminology.

The client who is four (4) months pregnant finds a lump in her breast and the biopsy is positive for Stage II cancer of the breast. Which treatment should the nurse anticipate the HCP recommending to the client? 1. A lumpectomy to be performed after the baby is born. 2. A modified radical mastectomy. 3. Radiation therapy to the chest wall only. 4. Chemotherapy only until the baby is born.

Answer: 2. A modified radical mastectomy is recommended for this client because the client is not able to begin radiation or chemotherapy, which are part of the regimen for a lumpectomy or wedge resection. Many breast cancers developed during pregnancy are hormone sensitive and have the ideal grounds for growth. The tumor should be removed as soon as possible. 1. Waiting until the baby is born allows the cancer to continue to develop and spread. This might be an option if the client were in the third trimester, but not at this early stage. 3. Radiation therapy cannot be delivered to a pregnant client because of possible harm to the fetus. 4. Chemotherapy is not given to the client while she is pregnant because of potential harm to the fetus. TEST-TAKING HINT: The test taker should eliminate options "3" and "4" because of potential harm to the fetus, but also because each option has the word "only." There are very few "onlys" in health care.

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

Answer: 2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces. 1. A pink and moist stoma indicates viable tissue and adequate circulation. A purple stoma indicates necrosis. 3. A red, bumpy, itchy rash indicates infection with the yeast Candida albicans, which should be treated with medication. 4. The ileostomy drainage has enzymes and bile salts, which are irritating and harsh to the skin; therefore, the pouch should be changed if any leakage occurs. TEST-TAKING HINT: This is an "except" question, and the test taker must identify which option is not a correct action for the nurse to implement. Sometimes flipping the question—"Which interventions indicate the client understands the teaching?"—can assist in identifying the correct answer.

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

Answer: 2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L. 1. The HCP should be notified so potassium supplements can be ordered, but this is not the first intervention. 3. Hypokalemia can lead to cardiac dysrhythmias; therefore, requesting telemetry is appropriate, but it is not the first intervention. 4. The client will need potassium to correct the hypokalemia, but it is not the first intervention. TEST-TAKING HINT: When the question asks which action should be implemented first, remember assessment is the first step in the nursing process. If the answer option addressing assessment is appropriate for the situation in the question, then the test taker should select it as the correct answer.

The nurse is reviewing the laboratory data on a male client. Which interpretation should the nurse make regarding the prostate-specific antigen (PSA)? Prostate-specific antigen Client value: 6 mcg/L Normal range: Male: <4 mcg/L, Female: <0.5 mcg/L 1. The client has early-stage prostate cancer. 2. The client should have more tests. 3. The client does not have prostate cancer. 4. The client has benign prostatic hypertrophy.

Answer: 2. The PSA is elevated and more tests should be completed to determine the cause. PSA levels are increased in benign prostatic hypertrophy, urinary retention, prostatic infarct, and prostate cancer. 1. The client may have cancer of the prostate, but this test does not provide conclusive results. There are several reasons for the PSA to be elevated, not just cancer. 3. Cancer cannot be eliminated as a diagnosis until other tests have been completed. 4. This may be the actual diagnosis, but the client should undergo more tests to confirm a diagnosis.

The client had a mastectomy for cancer of the breast and asks the nurse about a TRAM flap procedure. Which information should the nurse explain to the client? 1. The surgeon will insert a saline-filled sac under the skin to simulate a breast. 2. The surgeon will pull the client's own tissue under the skin to create a breast. 3. The surgeon will use tissue from inside the mouth to make a nipple. 4. The surgeon can make the breast any size the client wants the breast to be.

Answer: 2. The TRAM flap procedure is one in which the client's own tissue is used to form the new breast. Abdominal tissue and fat are pulled under the skin with one end left attached to the site of origin to provide circulation until the body builds collateral circulation in the area. 1. This is done for reconstruction of a breast or augmentation of breast size, but it is not a TRAM flap procedure, which uses the client's own tissue. 3. The plastic surgeon can rebuild a nipple from pigmented skin donor sites or can Tattoo the nipple in place. 4. This is true of saline implants but not of TRAM flaps. TEST-TAKING HINT: If the test taker is taking a standard pencil-and-paper test and is not familiar with this procedure, then skipping the question and returning to it at a later time is advisable. Another question might give a clue about the procedure. This is not possible on the NCLEX-RN computerized examination.

The client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client? 1. Ask if the client is afraid of having general anesthesia. 2. Determine how the client feels about radiation and chemotherapy. 3. Tell the client she will need reconstruction with either procedure. 4. Find out if the client has any history of breast cancer in her family.

Answer: 2. The client should understand the treatment regimen for follow-up care. A lumpectomy requires follow-up with radiation therapy to the breast and then systemic chemotherapy. If the cancer is in its early stages, this regimen has results equal to those with a modified radical mastectomy. 1. General anesthesia is used for either procedure. 3. A lumpectomy removes only the tumor and a small amount of tissue surrounding the tumor; reconstruction is not needed. 4. A history of breast cancer in the family is immaterial because this client has breast cancer. TEST-TAKING HINT: The test taker should use the nursing process to answer this question and select an assessment intervention, which eliminates option "3" as a correct answer. Option "1" uses the word "afraid," which is an assumption; therefore, this option could be eliminated.

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

Answer: 2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration. 1. The client's bowel should be placed on rest and no foods or fluids should be introduced into the bowel. 3. The vital signs must be taken more often than daily in a client who is having an acute exacerbation of ulcerative colitis. 4. The client will receive anti-inflammatory and antidiarrheal medications, not antacids, which are used for gastroenteritis. TEST-TAKING HINT: "Acute exacerbation" is the key phrase in the stem of the question. The word "acute" should cause the test taker to eliminate any daily intervention.

The client is diagnosed with left mastitis. Which assessment findings should the nurse observe? 1. Dimpling of the left breast when the client raises the arm. 2. A round lump in the left breast which is tender during menses. 3. A dull pain in the left breast and tough, doughy-feeling skin. 4. Bloody discharge from the nipple and a hard palpable mass.

Answer: 3. Mastitis is an infection of the breast occurring most often in women who are lactating. The breast becomes red and warm to touch. The skin becomes doughy and tough in consistency, and the client develops a dull pain in the affected breast. 1. Dimpling of the breast indicates a tumor has attached itself to the chest wall. 2. This indicates fibrocystic changes in the left breast. 4. Bloody discharge indicates a tumor, benign or malignant.

The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make? 1. The hospital social worker. 2. CanSurmount. 3. Reach to Recovery. 4. I CanCope.

Answer: 3. Reach to Recovery is a specific referral program for clients diagnosed with breast cancer. 1. The social worker assists clients in finding nursing home placement and financial arrangements, and does some work with clients to discuss feelings, but this is not the best referral. 2. CanSurmount volunteers work with all types of clients diagnosed with cancer, not just clients with breast cancer. 4. I CanCope is a cancer education program for all clients diagnosed with cancer and their significant others. TEST-TAKING HINT: The question asks for the most appropriate referral, and the test taker should choose the one specific to breast cancer.

Which recommendation is the American Cancer Society's (ACS) guideline for the early detection of breast cancer? 1. Beginning at age 18, have a biannual clinical breast examination by an HCP. 2. Beginning at age 30, perform monthly breast self-exams. 3. Beginning at age 40, receive a yearly mammogram. 4. Beginning at age 50, have a breast sonogram every five (5) years.

Answer: 3. The ACS recommends a yearly mammogram for the early detection of breast cancer. A mammogram can detect disease that will not be large enough to feel. 1. Unless there is a personal history of breast cancer or a strong family history, clinical breast examinations should begin at age 30 years and should be performed yearly. 2. If the client is going to perform breast selfexamination (BSE), it should begin at age 18. The ACS no longer includes monthly BSE as part of its guidelines. 4. Breast sonograms are performed to diagnose specific breast disease when a screening mammogram has shown a suspicious area. TEST-TAKING HINT: This is a knowledge based question. The test taker might be swayed by the option about BSE, but the age must be considered.

The client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast self-care? 1. This is a benign process which does not require follow-up. 2. The client should eliminate chocolate and caffeine from the diet. 3. The client should practice breast self-examination monthly. 4. This is the way breast cancer begins and the client needs surgery.

Answer: 3. The American Cancer Society no longer recommends breast self-examination (BSE) for all women, but it is advisable for women with known breast conditions to perform BSE monthly to detect potential cancer. 1. This is symptomatic of benign fibrocystic disease, but follow-up is always needed if the lumps do not go away when the hormone levels change. 2. Some practitioners suggest eliminating caffeine and chocolate from the diet if the breasts become tender from the changes, but there is no research supporting this to be effective in controlling the discomfort associated with fibrocystic breasts. 4. The client may need a breast biopsy for potential breast cancer at some point, but breast cancer develops when there is an alteration in the DNA of a cell. TEST-TAKING HINT: The test taker could eliminate option "1" because of the clause "does not require follow-up." The question is asking about self-care, and only two (2) options—"2" and "3"— involve the client doing something. The test taker should choose between these.

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

Answer: 3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk. 1. The nurse should never tell a client he or she understands what the client is going through. 2. Telling the client to think about the good things is not addressing the client's feelings. 4. The client is crying and states "I can't take it anymore," but this is not a suicidal comment or situation. TEST-TAKING HINT: There are rules applied to therapeutic responses. Do not say "understand" and do not ask "why." The test taker should select an option where some type of feeling is being reflected in the statement.

The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac workup for chest pain. Which intervention is most important for the nurse to implement? 1. Determine when the client had chemotherapy last. 2. Ask the client if she received Adriamycin, an antineoplastic agent. 3. Post a message at the head of the bed to not use the right arm. 4. Examine the chest wall for cancer sites

Answer: 3. The nurse should post a message at the head of the client's bed to not use the right arm for blood pressures or laboratory draws. This client is at risk for lymphedema, and this is a lymphedema precaution. 1. A client four (4) years postmastectomy should be finished with adjuvant therapy, which lasts from six (6) months to one (1) year. 2. The client may have received Adriamycin, which is a cardiotoxic medication, but knowing this will not change the tests performed or preparation for the tests. 4. The chest wall is sometimes involved in breast cancer, but the most important intervention is to prevent harm to the client. TEST-TAKING HINT: The question is asking for an intervention common in the healthcare industry. There are many breast cancer survivors who go on to develop unrelated problems, but the nurse must still be aware of the lingering needs of the client.

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

Answer: 3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output. 1. Weighing the client daily will help identify if the client is experiencing malnutrition, but it is ot the priority intervention during an acute exacerbation. 2. Coping strategies help develop healthy ways to deal with this chronic disease, which has remissions and exacerbations, but it is not the priority intervention. 4. The client will be NPO when there is an acute exacerbation of IBD to allow the bowel to rest. TEST-TAKING HINT: The test taker can apply Maslow's hierarchy of needs and select the option addressing a physiological need.

The nurse is performing the admission assessment on a 78-year-old female client and observes bilateral pendulous breasts with a stringy appearance. Which intervention should the nurse implement? 1. Request a mammogram. 2. Notify the HCP of the finding. 3. Continue with the examination. 4. Assess for peau d'orange skin.

Answer: 3. These are normal findings in the postmenopausal breast. Glandular tissue is replaced with fibrous tissue, the breasts become pendulous, and the Cooper's ligaments become prominent. 1. These are normal findings in a postmenopausal breast and do not require a mammogram. The client should have a mammogram yearly. 2. These are normal findings in the postmenopausal breast so there is no need to notify the HCP. 4. Peau d'orange skin occurs in advanced breast cancer.

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160.

Answer: 3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed. 1. Steroids can cause erosion of the stomach and should be taken with food. 2. A moon face is an expected side effect of steroids. 4. Steroids may increase the client's blood glucose, but diabetic medication regimens are usually not altered for the short period of time the client with an acute exacerbation is prescribed steroids. TEST-TAKING HINT: The test taker should know few medications must be taken on an empty stomach, which would cause option "1" to be eliminated. All medications should be taken as prescribed—don't think the answer is too easy.

The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group? 1. The clients should find out about their family history of breast cancer. 2. Men at this age can get breast cancer also and should be screened. 3. Monthly breast self-examination is the key to early detection. 4. The older a woman gets, the greater the chance of developing breast cancer.

Answer: 4. The greatest risk factor for developing breast cancer is being female. The second greatest risk factor is being elderly. By age 80, one (1) in every eight (8) women develops breast cancer. 1. Most women who develop breast cancer do not have a family history of the disease. Specific genes—BRCA-1 and BRCA-2—implicated in the development of breast cancer have been identified, but most women with breast cancer do not have these genes. 2. Approximately 1,000 men are diagnosed every year with breast cancer, but, as with women, it can occur at any age. Breast cancer in men frequently goes undetected because men consider this a woman's disease. 3. Mammograms can detect breast cancer earlier than breast self-examination and are the current recommendation by the American Cancer Society. TEST-TAKING HINT: The test taker cannot overlook the age when it is given in a question. "Senior citizen's center" should alert the test taker to the older age group. The test taker should decide what the age has to do with the answer.

The client is being discharged after a left wedge resection. Which discharge instructions should the nurse include? Select all that apply. 1. Notify the HCP of a temperature of 100˚F. 2. Carry large purses and bundles with the right hand. 3. Do not go to church or anywhere with crowds. 4. Try to keep the arm as still as possible until seen by the HCP. 5. Have a mammogram of the right and left breast yearly.

Answers: 1., 2., 5. 1. It is a common instruction for any client who has had surgery to notify the HCP if a fever develops. This could indicate a postoperative infection. 2. The client who has had a mastectomy is at risk for lymphedema in the affected arm because the lymph nodes are removed during the surgery. The client should protect the arm from injury and carry heavy objects with the opposite arm. 5. The client has developed a malignancy in one breast and is at a higher risk for developing another tumor in the remaining breast area. 3. The client can attend church services and large gatherings. This client had surgery, not chemotherapy, which would make the client immunosuppressed. 4. The client should be taught arm-climbing exercises before leaving the hospital to facilitate maintaining range of motion. TEST-TAKING HINT: The test taker must determine if the option of keeping the arm still is recommended. Most postoperative recommendations require the client to move as much as possible.