Exam Four

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Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? a. Increased thyroxine (T4) level b. Blood pressure 112/62 mm Hg c. Distant and difficult to hear heart sounds d. Elevated thyroid stimulating hormone level

A An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine

A patient will need vascular access for hemodialysis. Which statement by the nurseaccurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.

A Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them tomature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Importance of genetic counseling b. Complications of renal transplantation c. Methods for treating chronic and severe pain d. Differences between hemodialysis and peritoneal dialysis

A Because a 32-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.DIF: Cognitive Level: Application REF: 1143

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b. Apical pulse rate at rest 112 beats/minute c. Elevation in the patient's T3 and T4 levels d. Bruit audible bilaterally over the thyroid gland

A Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression. The other findings will also be reported but are expected with Hashimoto's thyroiditis and do not require immediate action

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital? a. Avoid unnecessary catheterizations. b. Encourage adequate oral fluid intake. c. Test urine with a dipstick daily for nitrites. d. Provide thorough perineal hygiene to patients.

A Since catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.DIF: Cognitive Level: Application REF: 1125-1127

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia.Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

A Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (asindicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, bloodglucose, and LOC would not affect the nurse's decision to give the medication.

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.DIF: Cognitive Level: Application REF: 1430-1431

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy

A Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing.

A The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.DIF: Cognitive Level: Application REF: 1447 | 1448

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? a. Excess fluid volume related to low serum protein levels b. Activity intolerance related to increased weight and fatigue c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

A The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses also are appropriate, but the focus of nursing care should be resolution of the edema and ascites.DIF: Cognitive Level: Application REF: 1133-1135

When caring for a patient with a left arm arteriovenous fistula, which action will thenurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use? a. Provide written reminders of self-care information. b. Offer multiple options for management of therapies. c. Ensure privacy for teaching by asking visitors to leave. d. Delay teaching until patient discharge date is confirmed.

A Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid

Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm? a. Propranolol (Inderal) b. Propylthiouracil (PTU) c. Methimazole (Tapazole) d. Iodine (Lugol's solution)

A b-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function

Which information will be included when the nurse is teaching self-management to apatient who is receiving peritoneal dialysis (select all that apply)? a. Avoid commercial salt substitutes. b. Restrict fluid intake to 1000 mL daily. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

A, C, D Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is not limited unless weight and blood pressure are notmcontrolled. Dairy products are high in phosphate and usually are limited.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)? A. Vision loss B. Cerebral edema C. Pituitary dysfunction D. Parathyroid dysfunction E. Focal neurologic deficits

A,B,C,E Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe

A. Frontal lobe

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and hairpieces or other methods to disguise hair loss a. during pre operative teaching b. in the patient asks about their use c. in the immediate postoperative period d. when the patient expresses negative feelings about his or her appearance

A. The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in surgery while the patient is anesthetized and that methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria,anemia, and hyperkalemia. Which prescribed action should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor thecardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. Thecatheter allows monitoring of the urine output but does not correct the cause of the renal failure.

Which information will the nurse monitor in order to determine the effectiveness ofprescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

Which nursing action should the nurse who is caring for a patient who has had an ileal conduit for several years delegate to nursing assistive personnel (NAP)? a. Assess for symptoms of urinary tract infection (UTI). b. Change the ostomy appliance. c. Choose the appropriate ostomy bag. d. Monitor the appearance of the stoma.

B Changing the ostomy appliance for a stable patient could be done by NAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the RN.DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158

After obtaining the health history for a 25-year-old who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.DIF: Cognitive Level: Application REF: 1145-1146

A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider? a. The patient is using opioids for pain. b. The patient has noticed clots in the urine. c. The patient is very anxious about the cancer. d. The patient is voiding every 4 hours at night.

B Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.DIF: Cognitive Level: Application REF: 1145-1146

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysiswith 2-L inflows. Which information should the nurse report promptly to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

B Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursinginterventions such as slowing the inflow and repositioning the patient.

A patient has arrived for a scheduled hemodialysis session. Which nursing action ismost appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of theappropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes hydrocortisone twice daily

B Emergency treatment of tetany requires IV administration of calcium; ECG monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany

Which nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-year-old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

B Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?"

B Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. hot, flushed face and neck. d. bounding peripheral pulses.

B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try toregulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis.Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first? a. Insert a straight catheter and drain the bladder. b. Assist the patient to take a 15-minute sitz bath. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.

B Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possibleDIF: Cognitive Level: Application REF: 1146

A patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Catheterization technique and schedule c. Analgesic use before emptying the pouch d. Use of barrier products for skin protection

B The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.DIF: Cognitive Level: Application REF: 1155-1156

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury(AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2

B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The otherinformation is typical of AKI and will not require a change in therapy.

A 37-year-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information is most important to communicate to the surgeon? a. The patient reports 7/10 incisional pain. b. The patient has increasing neck swelling. c. The patient is sleepy and difficult to arouse. d. The patient's cardiac rate is 112 beats/minute.

B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the stomach flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks thenurse, "Do you think I should go on dialysis? Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

B The nurse should initially clarify the patient's concerns and questions about dialysis. The patient is the one responsible for the decision, and many people using dialysis do have good quality of life, but these responses block further assessment of the patient's concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient's question.

Which nursing action will be included in the plan of care for a 55-year-old patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful

Which intervention will be included in the plan of care for a patient with acute kidneyinjury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.

B The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor

During routine hemodialysis, a patient complains of nausea and dizziness. Whichaction should the nurse take first? a. Slow down the rate of dialysis. b. Check the blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

B The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be tocheck the BP. The other actions may also be appropriate based on the blood pressure obtained.

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. readiness for enhanced coping related to need for information. d. self-care deficit, toileting, related to denial of altered body function.

B The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present.DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.

B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

A patient who has had progressive chronic kidney disease (CKD) for several years hasjust begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

B When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet isencouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor of the a. ventricles b. frontal lobe c. parietal lobe d. occipital lobe

B. Frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, and personality changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, disturbances in sensation and perception, and even seizures, that occur with other tumors are more likely to be understood and accepted by the family

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B.High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority

Which assessment finding may indicate that a patient is experiencing adverse effects toa corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

C Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over aprolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A. Codeine B. Phenytoin (Dilantin) C. Ceftriaxone (Rocephin) D. Acetaminophen (Tylenol)

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Incisional pain level is 8/10. c. Urine output is 20 mL/hr for 2 hours. d. Crackles are heard at both lung bases.

C Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.DIF: Cognitive Level: Application REF: 1154-1155

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider? a. Dysuria b. Hematuria c. Left-sided flank pain d. Temperature 100.1° F

C Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).DIF: Cognitive Level: Application REF: 1132-1133

A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Whichinformation will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renalfunction.

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive aprescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of greater than 12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

Before administration of calcium carbonate to a patient with chronic kidney disease\(CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.

C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. Calciumcarbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? A. Seizure disorders may occur in weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.

C In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.

C Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease although surgery may be used

A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

C Oral phosphate binders should not be given at the same time as iron because they prevent the iron frombeing absorbed. The phosphate binder should be given with a meal and the iron given at a different time.The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating a. milk and dairy products. b. legumes and dried fruits. c. organ meats and sardines. d. spinach, chocolate, and tea.

C Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.DIF: Cognitive Level: Application REF: 1139

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.

C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Which menu choice by the patient who is receiving hemodialysis indicates that thenurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high insalt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairyproducts are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.

A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency

Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous drainage from stoma

C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

The nurse prepares to administer temozolomide (Temodar) to a 59-year-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. Serum potassium and serum sodium levels B. Urine osmolality and urine specific gravity C. Absolute neutrophil count and platelet count D. Cerebrosprinal fluid (CSF) pressure and cell count

C Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be >1500/μL and platelet count >100,000/μL.

A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Infuse 5% dextrose in normal saline at 75 mL/hr. b. Order regular diet after patient is awake and alert. c. Give ketorolac (Toradol) 10 mg PO PRN for pain. d. Obtain blood urea nitrogen (BUN), creatinine, and electrolytes in 2 hours.

C The NSAIDs should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.DIF: Cognitive Level: Application REF: 1142-1143

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Foul-smelling urine b. Complaint of flank pain c. Blood pressure 88/45 mm Hg d. Temperature 100.1° F (57.8° C)

C The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.DIF: Cognitive Level: Application REF: 1126

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

C The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

When assessing a 30-year-old man who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of a. bladder infection. b. recent kidney trauma. c. gonococcal urethritis. d. benign prostatic hyperplasia.

C The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.DIF: Cognitive Level: Application REF: 1141

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.

C The patient's complaints suggest the development of distal ischemia (steal syndrome) and may requirerevision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain andcoolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

Which assessment finding for a 33-year-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? a. Bilateral exophthalmos b. Heart rate 136 beats/minute c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg

C The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications

The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? A. Administer IV mannitol (Osmitrol). B. Ventilator use to hyperoxygenate the patient C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to leaking CSF.

C The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient a. about radioactive precautions to take with all body secretions. b. that symptoms of hyperthyroidism should be relieved in about a week. c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. d. to discontinue the antithyroid medications taken before the radioactive therapy.

C There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed

An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering a. docusate (Colace). b. ibuprofen (Motrin). c. diazepam (Valium). d. cefoxitin (Mefoxin).

C Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient

A patient with Addison's disease comes to the emergency department with complaints of nausea, vomiting, diarrhea and fever. The nurse would expect collaborative care to include which of the following? A. Parenteral injections of ACTH. B. . IV administration of vasopressors. C. IV administration of hydrocortisone. D. IV administration of D%W with 20 mEq of Kcl.

C. RATIONALE: (3) Vomiting and diarrhea are early indications of addisonian crisis, and fever is indicative of infection which is causing more stress on the body. Treatment of a crisis requires immediate glucocorticoid replacement. ACTH is not effective. Potassium levels are increased with Addison's, thus KCl would be contraindicated.

What is essential teaching in treating a patient with Bell's palsy? A. Perform eye exercises to maintain strength. B. Obtain a herpes simplex virus (HSV) immunization. C. Do not abruptly stop the corticosteroids. D. Vigorously massage the area to promote circulation.

C. Do not abruptly stop the corticosteroids.Corticosteroids are usually started immediately. After they are no longer necessary, they should be tapered. Other treatment includes moist heat, gentle massage, and antiviral medications, such as acyclovir (Zovirax). Eye exercises are not indicated. HSV is identified in 70% of infections, but immunization is not beneficial at this point. Antiviral drugs may be used. Vigorous massage can break down tissues, but gentle upward massage has psychologic benefits.

To prevent the recurrence of renal calculi, the nurse teaches the patient to: a. use a filter to strain all urine. b. avoid dietary sources of calcium. c. drink diuretic fluids such as coffee. d. have 2000 to 3000 mL of fluid a day.

D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider? a. Blood in urine b. Left flank pain c. Left flank bruising d. Drop in urine output

D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.DIF: Cognitive Level: Application REF: 1138-1139

A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

D Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.DIF: Cognitive Level: Application REF: 1148

A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Apply absorbent incontinent pads. b. Restrict fluids after the evening meal. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.DIF: Cognitive Level: Application REF: 1151-1152

A patient complains of leg cramps during hemodialysis. The nurse should a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. nausea. b. flank pain. c. poor urine output. d. pain with urination.

D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.DIF: Cognitive Level: Application REF: 1123-1124

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Using an alcohol-based hand cleaner before performing catheter care d. Disconnecting the catheter from the drainage tube to obtain a specimen

D The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.DIF: Cognitive Level: Application REF: 1152-1154

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Review the chart for the patient's current creatinine level. d. Check the medical record for the most recent potassium level.

D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recentpotassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of theQRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

D The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

D The patient who has tachycardia after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments orinterventions but are not at risk for life-threatening complications.

A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about a. premedicating to prevent nausea. b. where to obtain wigs and scarves. c. the importance of oral care during treatment. d. the need to empty the bladder before treatment.

D The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy.DIF: Cognitive Level: Application REF: 1146

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of a. mosquito or tick bites b. chickenpox or measles c. cold sores or fever blisters d. an upper respiratory infection

D. Meningitis is often a result of an upper respiratory infection or middle ear infection, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes, and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

A patient is suspected of having a brain tumor. The s/s include: memory deficits, visual disturbances, weakness of right upper and lower extremities and personality changes. The nurse recognizes that the tumor is most likely located in the a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe

a Rationale: A unilateral frontal lobe tumor may result in the following signs and symptoms: unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, and visual disturbances. A bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an ataxic gait.

Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate

a, b, d. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.

The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)? a. Dry skin b. Sensory neuropathy c. Vascular calcifications d. Calcium-phosphate skin deposits e. Uremic crystallization from high BUN

a, b, d. Pruritus is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular disease, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.

Which characteristics describe the use of RAI (select all that apply)? a. Often causes hypothyroidism over time b. Decreases release of thyroid hormones c. Blocks peripheral conversion of T4 to T3 d. Treatment of choice in nonpregnant adults e. Decreases thyroid secretion by damaging thyroid gland f. Often used with iodine to produce euthyroid before surgery

a, d, e. RAI causes hypothyroidism over time by damaging thyroid tissue and is the treatment of choice for nonpregnant adults. Potassium iodide decreases the release of thyroid hormones and decreases the size of the thyroid gland preoperatively. Propylthiouracil (PTU) blocks peripheral conversion of T4 to T3 and may be used with iodine to produce a euthyroid state before surgery.

A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.

a. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

Which statement accurately describes Graves' disease? a. Exophthalmos occurs in Graves' disease. b. It is an uncommon form of hyperthyroidism. c. Manifestations of hyperthyroidism occur from tissue desensitization to the sympathetic nervous system. d. Diagnostic testing in the patient with Graves' disease will reveal an increased thyroid-stimulating hormone(TSH) level.

a. Exophthalmos or protrusion of the eyeballs may occurin Graves' disease from increased fat deposits and fluid in the orbital tissues and ocular muscles, forcing the eyeballs outward. Graves' disease is the most common form of hyperthyroidism. Increased metabolic rate and sensitivityof the sympathetic nervous system lead to the clinical manifestations. Thyroid-stimulating hormone (TSH) level is decreased in Graves' disease.

During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant.

a. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidneywas removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.

A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, what should the nurse expect to find? a. Hypertension, peripheral edema, and petechiae b. Weight loss, buffalo hump, and moon face with acne c. Abdominal and buttock striae, truncal obesity, and hypotension d. Anorexia, signs of dehydration, and hyperpigmentation of the skin

a. The effects of adrenocortical hormone excess,especially glucocorticoid excess, include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility leading to petechiae. Clinical manifestations of adrenocortical hormone deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.

What preoperative instruction should the nurse give to the patient scheduled for a subtotal thyroidectomy? a. How to support the head with the hands when turning in bed b. Coughing should be avoided to prevent pressure on the incisionm c. Head and neck will need to remain immobile until the incision heals d. Any tingling around the lips or in the fingers after surgery is expected and temporary

a. To prevent strain on the suture line postoperatively, the patient's head must be manually supported while turning and moving in bed but range-of-motion exercises for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing and these should be carried out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery. This sign should be reported immediately.

A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula (AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur. c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.

a. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.

Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. a. Drain b. Dwell c. Inflow

a. 3; b. 2; c. 1

Number in sequence the following ascending pathologic changes that occur in the urinary tract in the presence of a bladder outlet obstruction. a. Hydronephrosis b. Reflux of urine into ureter c. Bladder detrusor muscle hypertrophy d. Ureteral dilation e. Renal atrophy f. Vesicoureteral reflux g. Large residual urine in bladder h. Chronic pyelonephritis

a. 6; b. 3; c. 1; d. 4; e. 8; f. 5; g. 2; h. 7

As a precaution for vocal cord paralysis from damage to the recurrent laryngeal nerve during thyroidectomy surgery, what equipment should be in the room in case it is needed for this emergency situation? a. Tracheostomy tray c. IV calcium gluconate b. Oxygen equipment d. Paper and pencil for communication

a. A tracheostomy tray is in the room to use if vocal cord paralysis occurs from recurrent laryngeal nerve damage or for laryngeal stridor from tetany. The oxygen equipment may be useful but will not improve oxygenation with vocal cord paralysis without a tracheostomy. IV calcium salts will be used if hypocalcemia occurs from parathyroid damage. The paper and pencil for communication may be helpful, especially if a tracheostomy is performed, but will not aid in emergency oxygenation of the patient.

Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that whichprocedure has the least residual effects with a positive outcome? a. Glycerol rhizotomy b. Gamma knife radiosurgery c. Microvascular decompression d. Percutaneous radiofrequency rhizotomy

a. Although percutaneous radiofrequency rhizotomy andmicrovascular decompression provide the greatest reliefof pain, glycerol rhizotomy causes less sensory loss andfewer sensory aberrations with comparable pain relief andless danger. Gamma knife radiosurgery provides precisehigh doses of radiation useful for persistent pain after other surgery.

Which classification of urinary tract infection (UTI) is described as infection of the renal parenchyma, renal pelvis, and ureters? a. Upper UTI b. Lower UTI c. Complicated UTI d. Uncomplicated UTI

a. An upper urinary tract infection (UTI) affects the renal parenchyma, renal pelvis, and ureters. A lower UTI is an infection of the bladder and/or urethra. A complicated UTI exists in the presence of obstruction, stones, or preexisting diseases. An uncomplicated UTI occurs in an otherwise normal urinary tract.

How is urinary function maintained during the acute phase of spinal cord injury? a. An indwelling catheter b. Intermittent catheterization c. Insertion of a suprapubic catheter d. Use of incontinent pads to protect the skin

a. During the acute phase of spinal cord injury, the bladderis hypotonic, causing urinary retention with the riskfor reflux into the kidney or rupture of the bladder. Anindwelling catheter is used to keep the bladder empty andto monitor urinary output. Intermittent catheterizationor other urinary drainage methods may be used in longtermbladder management. Use of incontinent pads isinappropriate because they do not help the bladder toempty.

Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder

a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.

The nurse plans care for the patient with APSGN based on what knowledge? a. Most patients with APSGN recover completely or rapidly improve with conservative management. b. Chronic glomerulonephritis leading to renal failure is a common sequela to acute glomerulonephritis. c. Pulmonary hemorrhage may occur as a result of antibodies also attacking the alveolar basement membrane. d. A large percentage of patients with APSGN develop rapidly progressive glomerulonephritis, resulting in kidneyfailure.

a. Most patients recover completely from acute poststreptococcal glomerulonephritis (APSGN) with supportive treatment. Chronic glomerulonephritis that progresses insidiously over years and rapidly progressive glomerulonephritis that results in renal failure within weeks or months occur in only a few patients with APSGN. In Goodpasture syndrome, antibodies are present against both the GBM and the alveolar basement membrane of the lungs and dysfunction of both renal and pulmonary are present.

The patient has a thoracic spinal cord lesion and incontinence that occurs equally during the day and night. What type of incontinence is this patient experiencing? a. Reflex incontinence b. Overflow incontinence c. Functional incontinence d. Incontinence after trauma

a. Reflex incontinence occurs with no warning, equally during the day and night, and with spinal cord lesions above S2. Overflow incontinence is when the pressure of urinein the overfull bladder overcomes sphincter control and is caused by bladder or urethral outlet obstruction. Functional incontinence is loss of urine resulting from cognitive, functional, or environmental factors. Incontinence after trauma or surgery occurs when fistulas have occurred or after a prostatectomy.

Which characteristic is more likely with acute pyelonephritis than with a lower UTI? a. Fever b. Dysuria c. Urgency d. Frequency

a. Systemic manifestations of fever and chills with leukocytosis and nausea and vomiting are more common in pyelonephritis than in a lower UTI. Dysuria, frequency, and urgency can be present with both.

Which urinary diversion is a continent diversion created by formation of an ileal pouch with a stoma for catheterization? a. Kock pouch b. Ileal conduit c. Orthotopic neobladder d. Cutaneous ureterostomy

a. The Kock pouch is a continent diversion createdby formation of an ileal pouch with an external stoma requiring catheterization. Ileal conduit is the most common incontinent diversion using a stoma of resected ileum with implanted ureters. Orthotopic neobladder is a new bladder from a reshaped segment of intestine in the anatomic position of the bladder with urine discharged through the urethra. A cutaneous ureterostomy diverts the ureter from the bladder to the abdominal skin but there is frequent scarring and strictures of the ureters, so ileal conduits are used more often.

Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injuryfollowing an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. Maintaining a patent airway b. Maintaining immobilization of the cervical spine c. Assessing the patient for head and other injuries d. Assessing the patient's motor and sensory function

a. The need for a patent airway is the first priority for anyinjured patient and a high cervical injury may decrease thegag reflex and the ability to maintain an airway as well asthe ability to breathe. Maintaining cervical stability is thena consideration, along with assessing for other injuries andthe patient's neurologic status.

A patient is admitted to the hospital with severe renal colic. The nurse's first priority in management of the patient is to a. administer opioids as prescribed. b. obtain supplies for straining all urine c. encourage fluid intake of 3-4L/day d. keep the patient NPO in preparation for surgery

a. administer opioids as prescribed.

A patient has an ileal conduit. In planning care for this patient, the nurse will anticipate: (Select all that apply) a. Monitoring for skin breakdown b. Teaching patient to self-cath every 4-6 hours c. Consulting enterostomal therapy d. Assessing patient for psychosocial stressors

a. c. d.

One of the nruse's most important roles in relation to acute poststreptococcal golmerulonephritis is to a. promote early diagnosis and treatment of sore throats and skin lesions b.encourage patients to obtain antibiotic therapy for upper respiratory tract infections c.teach patients with APSGN that long term prophylactic antibiotic therapy is necessary to prevent recurrence d.monitor patients for respiratory symptoms that indicate the disease is affecting the alveolar basement membrane

a. promote early diagnosis and treatment of sore throats and skin lesions

A patient is diagnosed with cluster headaches. The nurse knows that which characteristics are associated with this type of headache (select all that apply)? a. Family history b. Alcohol is the only dietary trigger c. Abrupt onset lasting 5 to 180 minutes d. Severe, sharp, penetrating head pain e. Bilateral pressure or tightness sensation f. May be accompanied by unilateral ptosis or lacrimation

b, c, d, f. Cluster headaches have only alcohol as a dietary trigger and have an abrupt onset lasting 5 minutes to 3 hours with severe, sharp, penetrating pain. Cluster headaches may be accompanied by unilateral ptosis, lacrimation, rhinitis, facial flushing or pallor and commonly recur several times each day for several weeks, with months or years between clustered attacks. Family history and nausea, vomiting, or irritability may be seen with migraine headaches. Bilateral pressure occurring between migraine headaches and intermittent occurrence over long periods of time are characteristics of tension-type headaches.

What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.

b. A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open.

During discharge teaching for the patient with Addison's disease, which statement by the patient indicates that the nurse needs to do additional teaching? a. "I should always call the doctor if I develop vomiting or diarrhea." b. "If my weight goes down, my dosage of steroid is probably too high." c. "I should double or triple my steroid dose if I undergo rigorous physical exercise." d. "I need to carry an emergency kit with injectable hydrocortisone in case I can't take my medication by mouth."

b. A weight reduction in the patient with Addison's disease may indicate a fluid loss and a dose of replacement therapy that is too low rather than too high. Because vomiting and diarrheaare early signs of crisis and because fluid and electrolytesmust be replaced, patients should notify their health care provider if these symptoms occur. Patients with Addison's disease are taught to take two to three times their usual dose of steroids if they become ill, have teeth extracted, or engage in rigorous physical activity and should always have injectable hydrocortisone available if oral doses cannot be taken.

In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)

b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.

A patient with hypothyroidism is treated with levothyroxine (Synthroid). What should the nurse include when teaching the patient about this therapy? a. Explain that alternate-day dosage may be used if side effects occur. b. Provide written instruction for all information related to the drug therapy. c. Assure the patient that a return to normal function will occur with replacement therapy. d. Inform the patient that the drug must be taken until the hormone balance is reestablished.

b. Because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Replacement therapy must be taken for life and alternate-day dosing is not therapeutic. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist.

The nurse has identified the nursing diagnosis of fatigue for a patient who is hypothyroid. What should the nurse do while caring for this patient? a. Monitor for changes in orientation, cognition, and behavior. b. Monitor for vital signs and cardiac rhythm response to activity. c. Monitor bowel movement frequency, consistency, shape, volume, and color. d. Assist in developing well-balanced meal plans consistent with level of energy expenditure.

b. Cardiorespiratory response to activity is important to monitor in this patient to determine the effect of activities and plan activity increases. Monitoring changes in orientation, cognition, and behavior are interventions for impaired memory. Monitoring bowels is needed to plan care for the patient with constipation. Assisting with meal planning will help the patient with imbalanced nutrition: more than body requirements to lose weight if needed.

To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.

b. Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

What is the priority nursing intervention during the management of the patient with pheochromocytoma? a. Administering IV fluids c. Administering β-adrenergic blockers b. Monitoring blood pressure d. Monitoring intake and output and daily weights

b. Pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla, which may cause severe, episodic hypertension; severe, pounding headache; and profuse sweating. Monitoring for a dangerously high BP before surgery is critical, as is monitoring for BP fluctuations during medical and surgical treatment.

A patient with Addison's disease comes to the emergency department with complaints of nausea, vomiting, diarrhea, and fever. What collaborative care should the nurse expect? a. IV administration of vasopressors b. IV administration of hydrocortisone c. IV administration of D5W with 20 mEq KCl d. Parenteral injections of adrenocorticotropic hormone (ACTH)

b. Vomiting and diarrhea are early indicators of Addisonian crisis and fever indicates an infection, which is causing additional stress for the patient. Treatment of a crisis requires immediate glucocorticoid replacement and IV hydrocortisone, fluids, sodium, and glucose are necessary for 24 hours. Addison's disease is a primary insufficiency of the adrenal gland and adrenocorticotropic hormone (ACTH) is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's disease. Potassium levels are increased in Addison's disease and KCl would be contraindicated.

Priority Decision: Following electrohydraulic lithotripsy for treatment of renal calculi, the patient has a nursing diagnosis of risk for infection related to the introduction of bacteria following manipulation of the urinary tract. What is the most appropriate nursing intervention for this patient? a. Monitor for hematuria. b. Encourage fluid intake of 3 L/day. c. Apply moist heat to the flank area. d. Strain all urine through gauze or a special strainer.

b. A high fluid intake maintains dilute urine, which decreases bacterial concentration in addition to washing stone fragments and expected blood through the urinary system following lithotripsy. High urine output also prevents supersaturation of minerals. Moist heat to the flank may be helpful to relieve muscle spasms during renal colic and all urine should be strained in patients with renal stones to collect and identify stone composition but these are not related to infection.

During assessment of the patient who has a nephrectomy, what should the nurse expect to find? a. Shallow, slow respirations b. Clear breath sounds in all lung fields c. Decreased breath sounds in the lower left lobe d. Decreased breath sounds in the right and left lower lobes

b. A nephrectomy incision is usually in the flank, just below the diaphragm or in the abdominal area. Although the patient is reluctant to breathe deeply because of incisional pain, the lungs should be clear. Decreased sounds and shallow respirations are abnormal and would require intervention.

In providing care for the patient with adult-onset polycystic kidney disease, what should the nurse do? a. Help the patient to cope with the rapid progression of the disease b. Suggest genetic counseling resources for the children of the patient c. Expect the patient to have polyuria and poor concentration ability of the kidneys d. Implement measures for the patient's deafness and blindness in addition to the renal problems

b. Adult-onset polycystic kidney disease is an inherited autosomal dominant disorder that often manifests afterthe patient has children but the children should receive genetic counseling regarding their life choices. The disease progresses slowly, eventually causing progressive renal failure. Hereditary medullary cystic disease causes poor concentration ability of the kidneys and classic Alport syndrome is a hereditary nephritis that is associated with deafness and deformities of the optic lens.

You are preparing a care plan for a patient with Cushing's disease. Which nursing diagnoses would you be sure to include? a. Imbalanced nutrition: Less than body requirements b. Disturbed body image related to weight gain, moon face, red cheeks c. Disturbed body image related to bronze pigmentation of the skin d. Risk for deficient fluid volume related to nausea, vomiting and diarrhea

b. Disturbed body image related to weight gain, moon face, red cheeks

What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia

b. Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia leads to an accelerated rate of bone remodeling and potentially to tetany. Hyponatremia may lead to confusion. Elevated sodium levels lead to edema, hypertension, and heart failure. Hypermagnesemia may decrease reflexes, mental status, and blood pressure.

Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care should the nurse provide? a. Suction the patient before allowing him to rest. b. Allow the patient to sleep as long as he feels sleepy. c. Stimulate the patient to increase his level of consciousness. d. Check the patient's level of consciousness every 15 minutes for an hour.

b. In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours and the nurse should allow the patient to sleep as long as necessary. Suctioning is performed only if needed and decreased level of consciousness is not a problem postictally unless a head injury has occurred during the seizure.

Which type of headache is suspected when the headaches are unilateral and throbbing, preceded by a prodrome of photophobia, and associated with a family history of this type of headache? a. Cluster b. Migraine c. Frontal-type d. Tension-type

b. Migraine headaches are frequently unilateral and usually throbbing. They may be preceded by a prodrome and frequently there is a family history. Cluster headaches are also unilateral with severe bone-crushing pain but there is no prodrome or family history. Frontal-type headache is not a functional type of headache. Tension-type headaches are bilateral with constant, squeezing tightness without prodrome or family history.

The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder.

b. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.

A patient has a right ureteral catheter placed following a lithotripsy for a stone in the ureter. In caring for the patient after the procedure, what is an appropriate nursing action? a. Milk or strip the catheter every 2 hours. b. Measure ureteral urinary drainage every 1 to 2 hours. c. Irrigate the catheter with 30-mL sterile saline every 4 hours. d. Encourage ambulation to promote urinary peristaltic action.

b. Output from ureteral catheters must be monitored every 1 to 2 hours because an obstruction will cause overdistention of the renal pelvis and renal damage. The renal pelvis hasa capacity of only 3 to 5 mL and if irrigation is ordered, no more than 5 mL of sterile saline is used. The patient witha ureteral catheter is usually kept on bed rest until specific orders for ambulation are given. Suprapubic tubes may be milked to prevent obstruction of the catheter by sediment and clots.

In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what? a. Total daily urine output b. Glomerular filtration rate c. Degree of altered mental status d. Serum creatinine and urea levels

b. Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD).

The female patient with a UTI also has renal calculi. The nurse knows that these are most likely which type of stone? a. Cystine b. Struvite c. Uric acid d. Calcium phosphate

b. Struvite calculi are most common in women and always occur with UTIs. They are also usually large staghorn type.

A female patient with a UTI has a nursing diagnosis of risk for infection related to lack of knowledge regarding prevention of recurrence. What should the nurse include in the teaching plan instructions for this patient? a. Empty the bladder at least 4 times a day. b. Drink at least 2 quarts of water every day. c. Wait to urinate until the urge is very intense. d. Clean the urinary meatus with an antiinfective agent after voiding.

b. The bladder should be emptied at least every 3 to 4 hours. Fluid intake should be increased to about 2000 mL/ day without caffeine, alcohol, citrus juices, and chocolate drinks, because they are potential bladder irritants. Cleaning the urinary meatus with an antiinfective agent after voiding will irritate the meatus but the perineal area should be wiped from front to back after urination and defecation to prevent fecal contamination of the meatus.

Which infection is asymptomatic in the male patient at first and then progresses to cystitis, frequent urination, burning on voiding, and epididymitis? a. Urosepsis b. Renal tuberculosis c. Urethral diverticula d. Goodpasture syndrome

b. The manifestations of renal tuberculosis are described.Urosepsis is when the UTI has spread systemically. Urethral diverticula are localized outpouching of the urethra and occur more often in women. Goodpasture syndrome manifests with flu-like symptoms with pulmonary symptoms that include cough, shortness of breath, and pulmonary insufficiency and renal manifestations that include hematuria, weakness, pallor, anemia, and renal failure.

What medication is used with thyrotoxicosis to block the effects of the sympathetic nervous stimulation of the thyroid hormones? a. Potassium iodide c. Propylthiouracil (PTU) b. Atenolol (Tenormin) d. Radioactive iodine (RAI)

b. The β-adrenergic blocker atenolol is used to blockthe sympathetic nervous system stimulation by thyroid hormones. Potassium iodide is used to prepare the patient for thyroidectomy or for treatment of thyrotoxic crisisto inhibit the synthesis of thyroid hormones. Antithyroid medications inhibit the synthesis of thyroid hormones. Radioactive iodine (RAI) therapy destroys thyroid tissue, which limits thyroid hormone secretion.

The immunologic mechanisms involved in acute poststreptococal glomerulonephritis include: a. tubular blocking by precipitates of bacteria and antibody reactions b. deposition of immune complexes and complement along the GBM c. thickening of the GBM from autoimmune microangiopathic changes d. destruction of glomeruli by proteolytic enzymes contained in the GBM

b. deposition of immune complexes and complement along the GBM

A patient with ureterolithotomy returns from surgery with a nephrostomy tube in place. Postoperative nursing care of the patient includes: a.encourage the patient to drink fruit juices and milk b.encouraging fluids of at least 2-3 L/day after nausea has subsided c. irrigating the nephrostomy tube with 10ml of NS solution as needed d. notifying the physician if nephrostomy tube drainage is more than 30ml/hr

b.encouraging fluids of at least 2-3 L/day after nausea has subsided

The nurse identifies a risk factor for kidney and bladder cancer in a patient who relates a history of a.aspirin use b.tobacco use c.chronic alcohol abuse d.use of artificial sweeteners

b.tobacco use

The nurse teaches the female paitent who has frequent UTIs that she should a. take tub baths with bubble bath b.urinate before and after sexual intercourse c.take prophylactic sufonamides for the rest of her life d. restrict fluid intake to prevent the need for frequent voiding

b.urinate before and after sexual intercourse

The nurse on clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting

c Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

Nursing management of a patient with a brain tumor includes (select all that apply): a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about anti seizure drugs.

c, e Rationale: Nursing interventions should be based on a realistic appraisal of the patient's condition and prognosis after cranial surgery. The nurse should provide support and education to the caregiver and family about the patient's behavioral changes. The nurse should be prepared to manage seizures and teach the caregiver and family about antiseizure medications and how to manage a seizure. An overall goal is to foster the patient's independence for as long as possible and to the highest degree possible. The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial pressure.

The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions

c, e. Peritoneal dialysis is less stressful for the cardiovascular system and requires fewer dietary restrictions. Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis.

A patient is admitted to the hospital with thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and laryngeal stridor b. Bulging eyeballs and dysrhythmias c. Elevated temperature and signs of heart failure d. Lethargy progressing suddenly to impairment of consciousness

c. A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with severe tachycardia, heart failure, shock, hyperthermia, restlessness, irritability, abdominal pain, vomiting, diarrhea, delirium, and coma. Although exophthalmos may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid crisis. Hoarseness and laryngeal stridor are characteristic of the tetany of hypoparathyroidism and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism.

A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein

c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.

A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia

c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.

What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood

c. Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Dialysate also usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention.

The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause this patient's Kussmaul respirations? a. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.

c. Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

A patient with mild iatrogenic Cushing syndrome is on an alternate-day regimen of corticosteroid therapy. What does the nurse explain to the patient about this regimen? a. It maintains normal adrenal hormone balance. b. It prevents ACTH release from the pituitary gland. c. It minimizes hypothalamic-pituitary-adrenal suppression. d. It provides a more effective therapeutic effect of the drug.

c. Taking corticosteroids on an alternate-day schedule for pharmacologic purposes is less likely to suppress ACTH production from the pituitary and prevent adrenal atrophy. Normal adrenal hormone balance is not maintained during glucocorticoid therapy because excessive exogenous hormone is used.

For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? a. Loss of aluminum through the impaired kidneys b. Deposition of calcium phosphate in soft tissues of the body c. Impaired vitamin D activation resulting in decreased GI absorption of calcium d. Increased release of parathyroid hormone in response to decreased calcium levels

c. The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed tocontribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.

During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.

c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.

What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD? a. High serum sodium levels b. Irritation of the GI tract from creatinine c. Increased ammonia from bacterial breakdown of urea d. Iron salts, calcium-containing phosphate binders, and limited fluid intake

c. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity cause constipation.

A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. What is the best response by the nurse? a. "So many factors can cause epilepsy that it is impossible to say what caused your seizure." b. "Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?" c. "In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity." d. "Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges."

c. A seizure is a paroxysmal, uncontrolled discharge of neurons in the brain, which interrupts normal function, but the factor that causes the abnormal firing is not clear. Seizures may be precipitated by many factors and although scar tissue may make the brain neurons more likely to fire, it is not the usual cause of seizures. Epilepsy is established only by a pattern of spontaneous, recurring seizures.

What is the most common cause of acute pyelonephritis resulting from an ascending infection from the lower urinary tract? a. The kidney is scarred and fibrotic. b. The organism is resistant to antibiotics. c. There is a preexisting abnormality of the urinary tract. d. The patient does not take all of the antibiotics for treatment of a UTI.

c. Ascending infections from the bladder to the kidneyare prevented by the normal anatomy and physiology ofthe urinary tract unless a preexisting condition, such as vesicoureteral reflux or lower urinary tract dysfunction (bladder tumors, prostatic hyperplasia, strictures, or stones), is present. Resistance to antibiotics and failure to take a full prescription of antibiotics for a UTI usually result in relapse or reinfection of the lower urinary tract.

What can patients at risk for renal lithiasis do to prevent the stones in many cases? a. Lead an active lifestyle b. Limit protein and acidic foods in the diet c. Drink enough fluids to produce dilute urine d. Take prophylactic antibiotics to control UTIs

c. Because crystallization of stone constituents can precipitate and unite to form a stone when in supersaturated concentrations, one of the best ways to prevent stones of any type is by drinking adequate fluids to keep the urine dilute and flowing (e.g., an output of about 2 L of urinea day). Sedentary lifestyle is a risk factor for renal stones but exercise also causes fluid loss and a need for additional fluids. Protein foods high in purine should be restricted only for the small percentage of patients with uric acid stones and although UTIs contribute to stone formation, prophylactic antibiotics are not indicated.

Which type of urinary tract calculi are the most common and frequently obstruct the ureter? a. Cystine b. Uric acid c. Calcium oxalate d. Calcium phosphate

c. Calcium oxalate calculi are most common and small enough to get trapped in the ureter.

The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with aspinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patientassessment? a. Heart rate of 68 bpm b. Respiratory rate of 24 c. Blood pressure of 106/82 mm Hg d. Temperature of 96.8°F (36.0°C)

c. Dopamine is a vasopressor that is used to maintainblood pressure during states of hypotension that occurduring neurogenic shock associated with spinal cordinjury. Atropine would be used to treat bradycardia. Thetemperature reflects some degree of poikilothermism butthis is not treated with medications.

Glomerulonephritis is characterized by glomerular damage caused by a. growth of microorganisms in the glomeruli. b. release of bacterial substances toxic to the glomeruli. c. accumulation of immune complexes in the glomeruli. d. hemolysis of red blood cells circulating in the glomeruli.

c. Glomerulonephritis is not an infection but rather an antibody-induced injury to the glomerulus, where either autoantibodies against the glomerular basement membrane (GBM) directly damage the tissue or antibodies reacting with nonglomerular antigens are randomly deposited as immune complexes along the GBM. Prior infection by bacteria or viruses may stimulate the antibody production but is not present or active at the time of glomerular damage.

Priority Decision: When teaching a patient with a seizure disorder about the medication regimen, what is it most important for the nurse to emphasize? a. The patient should increase the dosage of the medication if stress is increased. b. Most over-the-counter and prescription drugs are safe to take with antiseizure drugs. c. Stopping the medication abruptly may increase the intensity and frequency of seizures. d. If gingival hypertrophy occurs, the drug should be stopped and the health care provider notified.

c. If antiseizure drugs are discontinued abruptly, seizures can be precipitated. Missed doses should be made up if the omission is remembered within 24 hours and patients should not adjust medications without professional guidance because this also can increase seizure frequency and may cause status epilepticus. Antiseizure drugs have numerous interactions with other drugs and the use of other medications should be evaluated by health professionals. If side effects occur, the physician should be notified and drug regimens evaluated.

What results in the edema associated with nephrotic syndrome? a. Hypercoagulability b. Hyperalbuminemia c. Decreased plasma oncotic pressure d. Decreased glomerular filtration rate

c. The massive proteinuria that results from increased glomerular membrane permeability in nephroticsyndrome leaves the blood without adequate proteins (hypoalbuminemia) to create an oncotic colloidal pressure to hold fluid in the vessels. Without oncotic pressure,fluid moves into the interstitium, causing severe edema. Hypercoagulability occurs in nephrotic syndrome but is not a factor in edema formation and glomerular filtration rate (GFR) is not necessarily affected in nephrotic syndrome.

While caring for a 77-year-old woman who has a urinary catheter, the nurse monitors the patient for the development of a UTI. What clinical manifestations is the patient most likely to experience? a. Cloudy urine and fever b. Urethral burning and bloody urine c. Vague abdominal discomfort and disorientation d. Suprapubic pain and slight decline in body temperature

c. The usual classic manifestations of UTI are often absent in older adults, who tend to experience nonlocalized abdominal discomfort and cognitive impairment characterized by confusion or decreased level of consciousness rather than dysuria and suprapubic pain.

Thirty percent of patients with kidney cancer have metastasis at the time of diagnosis. Why does this occur? a. The only treatment modalities for the disease are palliative. b. Diagnostic tests are not available to detect tumors before they metastasize. c. Classic symptoms of hematuria and palpable mass do not occur until the disease is advanced. d. Early metastasis to the brain impairs the patient's ability to recognize the seriousness of symptoms.

c. There are no early characteristic symptoms of cancer of the kidney and gross hematuria, flank pain, and a palpable mass do not occur until the disease is advanced. The treatment of choice is a partial or radical nephrectomy, which can be successful in early disease. Many kidney cancers are diagnosed as incidental imaging findings. Targeted therapy is the preferred treatment for metastatic kidney cancer. Radiation is palliative. The most common sites of metastases are the lungs, liver, and long bones.

A woman with no history of UTIs who is experiencing urgency, frequency, and dysuria comes to the clinic, where a dipstick and microscopic urinalysis indicate bacteriuria. What should the nurse anticipate for this patient? a. Obtaining a clean-catch midstream urine specimen for culture and sensitivity b. No treatment with medication unless she develops fever, chills, and flank pain c. Empirical treatment with trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) for 3 days d. Need to have a blood specimen drawn for a complete blood count (CBC) and kidney function tests

c. Unless a patient has a history of recurrent UTIs or a complicated UTI, trimethoprim-sulfamethoxazole (TMP- SMX) or nitrofurantoin (Macrodantin) is usually usedto empirically treat an initial UTI without a culture and sensitivity or other testing. Asymptomatic bacteriuria does not justify treatment but symptomatic UTIs should always be treated.

What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Raisins b. Ice cream c. Dill pickles d. Hard candy

d. A patient with CKD may have unlimited intake of sugars and starches (unless the patient is diabetic) and hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content.

When replacement therapy is started for a patient with long-standing hypothyroidism, what is most important for the nurse to monitor the patient for? a. Insomnia c. Nervousness b. Weight loss d. Dysrhythmias

d. All these manifestations may occur with treatmentof hypothyroidism. However, as a result of the effectsof hypothyroidism on the cardiovascular system, when thyroid replacement therapy is started myocardial oxygen consumption is increased and the resultant oxygen demand may cause angina, cardiac dysrhythmias, and heart failure, so monitoring for dysrhythmias is most important.

Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR)

d. As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine.

What is a cause of primary hypothyroidism in adults? a. Malignant or benign thyroid nodules b. Surgical removal or failure of the pituitary gland c. Surgical removal or radiation of the thyroid gland d. Autoimmune-induced atrophy of the thyroid gland

d. Both Graves' disease and Hashimoto's thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland.

A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease

d. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.

A patient with Graves' disease asks the nurse what caused the disorder. What is the best response by the nurse? a. "The cause of Graves' disease is not known, although it is thought to be genetic." b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time." c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones." d. "In genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion."

d. In Graves' disease, antibodies to the TSH receptor are formed, attach to the receptors, and stimulate the thyroid gland to release triiodothyronine (T3), thyroxine (T4),or both, creating hyperthyroidism. The disease is not directly genetic but individuals appear to have a genetic susceptibility to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.

What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calciumlevels are increased.

d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.

When providing discharge instructions to a patient who had a subtotal thyroidectomy for hyperthyroidism, what should the nurse teach the patient? a. Never miss a daily dose of thyroid replacement therapy. b. Avoid regular exercise until thyroid function is normalized. c. Use warm saltwater gargles several times a day to relieve throat pain. d. Substantially reduce caloric intake compared to what was eaten before surgery.

d. With the decrease in thyroid hormone postoperatively, calories need to be reduced substantially to prevent weight gain. When a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. Regular exercise stimulates the thyroid gland and is encouraged. Saltwater gargles are used for dryness and irritation of the mouth and throat following radioactive iodine therapy.

Which test is required for a diagnosis of pyelonephritis? a. Renal biopsy b. Blood culture c. Intravenous pyelogram (IVP) d. Urine for culture and sensitivity

d. A urine specimen specifically obtained for culture and sensitivity is required to diagnose pyelonephritis because it will show pyuria, the specific bacteriuria, and what drug the bacteria is sensitive to for treatment. The renal biopsy is used to diagnose chronic pyelonephritis or cancer. Blood cultures would be done if bacteremia is suspected. Intravenous pyelogram (IVP) would increase renal irritation, but CT urograms may be used to assess for signs of infection in the kidney and complications of pyelonephritis.

What manifestation in the patient will indicate the need for restriction of dietary protein in management of acute poststreptococcal glomerulonephritis (APSGN)? a. Hematuria b. Proteinuria c. Hypertension d. Elevated blood urea nitrogen (BUN)

d. An elevated blood urea nitrogen (BUN) indicates that the kidneys are not clearing nitrogenous wastes from the blood and protein may be restricted until the kidney recovers. Proteinuria indicates loss of protein from the blood and possibly a need for increased protein intake. Hypertension is treated with sodium and fluid restriction, diuretics, and antihypertensive drugs. The hematuria is not specifically treated.

When caring for the patient with interstitial cystitis, what can the nurse teach the patient to do? a. Avoid foods that make the urine more alkaline. b. Use high-potency vitamin therapy to decrease the autoimmune effects of the disorder. c. Always keep a voiding diary to document pain, voiding frequency, and patterns of nocturia. d. Use the dietary supplement calcium glycerophosphate (Prelief) to decrease bladder irritation.

d. Calcium glycerophosphate (Prelief) alkalinizes the urine and can help to relieve the irritation from acidic foods. A diet low in acidic foods is recommended and ifa multivitamin is used, high-potency vitamins should be avoided because these products may irritate the bladder. A voiding diary is useful in diagnosis but does not need to be kept indefinitely.

What characteristic is related to Hashimoto's thyroiditis? a. Enlarged thyroid gland b. Viral-induced hyperthyroidism c. Bacterial or fungal infection of thyroid gland d. Chronic autoimmune thyroiditis with antibody destruction of thyroid tissue

d. In Hashimoto's thyroiditis, thyroid tissue is destroyed by autoimmune antibodies. An enlarged thyroid glandis a goiter. Viral-induced hyperthyroidism is subacute granulomatous thyroiditis. Acute thyroiditis is caused by bacterial or fungal infection.

In planning community education for prevention of spinal cord injuries, what group should the nurse target? a. Older men b. Teenage girls c. Elementary school-age children d. Adolescent and young adult men

d. Spinal cord injuries are highest in adolescent andyoung adult men between the ages of 16 and 30 andthose who are impulsive or risk takers in daily living.Other risk factors include alcohol and drug abuse as wellas participation in sports and occupational exposure totrauma or violence.

Which disease causes connective tissue changes that cause glomerulonephritis? a. Gout b. Amyloidosis c. Diabetes mellitus d. Systemic lupus erythematosus

d. Systemic lupus erythematosus causes connective tissue damage that affects the glomerulus. Gout deposits uric acid crystals in the kidney. Amyloidosis deposits hyaline bodies in the kidney. Diabetes mellitus causes microvascular damage affecting the kidney.

A patient who recently had a calcium oxalate renal stone had a bone density study, which showed a decrease in her bone density. What endocrine problem could this patient have? a. SIADH c. Cushing syndrome b. Hypothyroidism d. Hyperparathyroidism

d. The patient with hyperparathyroidism may have calcium nephrolithiasis, skeletal pain, decreased bone density, psychomotor retardation, or cardiac dysrhythmias. The other endocrine problems would not be related to calcium kidney stones or decreased bone density.

A patient with suprapubic pain and symptoms of urinary frequency and urgency has two negative urine cultures. What is one assessment finding that would indicate interstitial cystitis? a. Residual urine greater than 200 mL b. A large, atonic bladder on urodynamic testing c. A voiding pattern that indicates psychogenic urinary retention d. Pain with bladder filling that is transiently relieved by urination

d. The symptoms of interstitial cystitis (IC) imitate those of an infection of the bladder but the urine is free of infectious agents. Unlike a bladder infection, the pain with IC increases as urine collects in the bladder and is temporarily relieved by urination. Acidic urine is very irritating to the bladder in IC and the bladder is small but urinary retention is not common.

A patient with bladder cancer undergoes cystectomy with formation of an ileal conduit. During the patient's first postoperative day, what should the nurse plan to do? a. Measure and fit the stoma for a permanent appliance. b. Encourage high oral intake to flush mucus from the conduit. c. Teach the patient to self-catheterize the stoma every 4 to 6 hours. d. Empty the drainage bag every 2 to 3 hours and measure the urinary output.

d. Urine drains continuously from an ileal conduit andthe drainage bag must be emptied every 2 to 3 hours and measured to ensure adequate urinary output. Fitting for a permanent appliance is not done until the stoma shrinksto its normal size in a few weeks. With an ileal conduit, mucus is present in the urine because it is secreted by the ileal segment as a result of the irritating effect of the urine but the surgery causes paralytic ileus and the patient will be NPO for several days postoperatively. Self-catheterization is performed when patients have formation of a continent Kock pouch.

In teaching a patient with pyelonephritis about the disorder, the nurse informs the paitent that the organisms that cause pyelonephritis most commonly reach the kidneys through a. the bloodstream b.the lymphatic system c. a descending infection d. an ascending infection

d. an ascending infection

A patient has has a cystectomy and ileal conduit diversion performed. Four days postoperatively, mucous shred are seen in the drainage bag. The nurse should. a. notify the physician b.notify the charge nurse c. irrigate the drainage tube d. chart it as a normal observation

d. chart it as a normal observation

The nurse recommends genetic counseling for the children of a patient with a.nephrotic syndrome b.chronic pyelonephritis c. malignant nephrosclerosis d.adult onset polycystic kidney disease

d.adult onset polycystic kidney disease

The edema that occurs in nephrotic syndrome is due to a. increased hydrostatic pressure caused by sodium retention. b. decreased aldosterone secretion from adrenal insufficiency. c. increased fluid retention caused by decreased glomerular filtration d.decreased colloidal osmotic pressure caused by loss of serum albumin

d.decreased colloidal osmotic pressure caused by loss of serum albumin

Delegation Decision: Which nursing interventions could be delegated to unlicensed assistive personnel (UAP) (select all that apply)? a. Assess the need for catheterization. b. Use bladder scanner to estimate residual urine. c. Teach patient pelvic floor muscle (Kegel) exercises. d. Insert indwelling catheter for uncomplicated patient. e. Assist incontinent patient to commode at regular intervals. f. Provide perineal care with soap and water around a urinary catheter.

e, f. The unlicensed assistive personnel (UAP) mayassist the incontinent patient to void at regular intervalsand provide perineal care. An RN should performthe assessments and teaching. In long-term care and rehabilitation facilities, UAP may use bladder scanners after they are trained.

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1."I need to perform good oral hygiene, including flossing and brushing my teeth." 2."I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3."I should take my medication before coming to the laboratory to have a blood level drawn." 4."I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

1."I need to perform good oral hygiene, including flossing and brushing my teeth."The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1.Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements 5.What the client ate in the 2 hours preceding seizure activity

1.Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Option 5 is not a component of seizure assessment.

A nurse reviews the medical history with a patient and learns that the patient was diagnosed with restless legs syndrome. Based on this fact, which question should the nurse also ask? 1."Do you experience calf pain after walking a block?" 2."Are you able to sleep well and feel rested?" 3."Do you experience episodes where you are unable to move one leg?" 4."When exposed to cold do your legs turn pale, then blue, and become painful?"

2. Restless legs syndrome is a condition in which patients experience paresthesias, including numbness, tingling, pain, and restlessness in one or both legs. The condition occurs commonly at night, interferes with the patient's ability to sleep, and contributes to daytime fatigue. Asking whether the patient sleeps well and feels rested is appropriate. Calf pain that occurs with walking is termed intermittent claudication and is a symptom of peripheral vascular disease. A temporary episode of paralysis describes a transient ischemic attack (TIA), a precursor to a stroke. Raynaud's disease occurs in persons with connective tissue conditions and involves vasospasms in response to cold. The legs become pale, then cyanotic and often reddened post vasospasm. The episodes are painful.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination

2.Liver function studiesDivalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. Options 1, 3, and 4 are not studies that are required with the use of this medication.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1.Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2.Spasms of the entire bodyThe clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Options 1, 3, and 4 identify the tonic phase of a seizure.

A client had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1.Presence of diaphoresis 2.Loss of consciousness 3.History of prior trauma 4.Rotating eye movements

3.History of prior traumaSeizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or drug consumption. Options 1, 2, and 4 address signs, rather than an origin of the seizure.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs more information if he or she states an intention to take which action? 1.Refrain from smoking alone. 2.Take all prescribed medications on time. 3.Have the spouse nearby when showering. 4.Drink alcohol in small amounts and only on weekends.

4.Drink alcohol in small amounts and only on weekends.The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or the alcohol could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic drug levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about a. recent sore throat and fever. b. history of high blood pressure. c. frequency of bladder infections. d. family history of kidney stones.

A Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.DIF: Cognitive Level: Application REF: 1131-1132

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize? A. A mammogram is needed every year. B. Bladder function tends to improve with age. C. Heart disease is not common in persons with spinal cord injury. D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year.Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms

What is the best method to assess a patient with trigeminal neuralgia (tic douloureux)? A. Ask the patient what the triggering factors are. B. Have the patient open and close the jaw while palpating the mandible. C. Instruct the patient to touch the examiner's finger and then the patient's nose. D. Look at the optic disk with an ophthalmoscope

A. Ask the patient what the triggering factors are.The main symptom is spasms of severe, unilateral facial pain. Palpating the face may trigger a painful episode; touch is a common trigger. The other options do not reveal information about the trigeminal nerve effect.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minuteNeurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. BradycardiaNeurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

What should the patient with Bell's palsy be cautioned against? A. Cornea dryness B. Driving while experiencing diplopia C. Sudden movement of the head when bending over D. Contamination from the affected eye to the other eye

A. Cornea drynessWith Bell's palsy, the eyelid on the affected side often does not close tightly. Eye drops are used during the daytime, and patches are worn at night. The other options are not related to Bell's palsy.

What is the classic presentation of botulism? A. Descending flaccid paralysis B. Ascending bilateral paralysis C. Homonymous hemianopsia D. Vomiting and diarrhea

A. Descending flaccid paralysisNeurologic manifestations can develop rapidly or evolve over several days. They include the development of a descending flaccid paralysis with intact sensation, photophobia, ptosis, paralysis of extraocular muscles, blurred vision, diplopia, dry mouth, sore throat, and difficulty in swallowing. Ascending bilateral paralysis is associated with Guillain-Barré syndrome. Homonymous hemianopsia, the loss of one half of the field of vision, can occur in a stroke

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds

A. Headache and rising blood pressureAmong the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

During assessment of the patient with trigeminal neuralgia, what should you do (select all that apply)? A. Inspect all aspects of the mouth and teeth. B. Assess the gag reflex and respiratory rate and depth. C. Lightly palpate the affected side of the face for edema. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode.

A. Inspect all aspects of the mouth and teeth. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode.Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps you plan patient care. The painful episodes are usually initiated by a triggering mechanism of light cutaneous stimulation at a specific point (trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, and talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in temperature.

What is a classic manifestation of tetanus infection? A. Rigidity and seizures B. Bloody diarrhea and vomiting C. Pulmonary edema D. Sepsis

A. Rigidity and seizuresThe manifestations are mainly neurologic. They include stiffness in the jaw (trismus), generalized tonic convulsions, and opisthotonos. Laryngeal and respiratory spasms can also occur. The other options are not related to tetanus.

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position

A. Urinary catheterizationBecause the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "Call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents prevents Bell's palsy." c. "You may be able to prevent Bell's palsy by doing facial exercises regularly." d. "Medications to treat Bell's palsy work only if started before paralysis onset."

ANS: APain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.

ANS: AThe patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? a. Remind the patient about the need to drink 1000 mL of fluids daily. b. Obtain a midstream urine specimen for culture and sensitivity testing. c. Teach the patient to take the prescribed Bactrim for at least 3 more days. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: BSince uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Tylenol would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Since the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.DIF: Cognitive Level: Application REF: 1123-1125

A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to a. obtain the patient's temperature. b. administer an intradermal test dose. c. ask the patient about a history of egg allergies. d. document the presence of neurologic symptoms.

ANS: BTo prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.

The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one will the nurse question? a. Maintain NPO status. b. Obtain lumbar puncture tray. c. Give magnesium citrate 8 oz now. d. Administer 1500-mL tap water enema.

ANS: CMagnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Take the medication for at least 7 days. b. Use sunscreen while taking the Pyridium. c. The urine may turn a reddish-orange color. d. Use the Pyridium before sexual intercourse.

ANS: CPatients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI. Pyridium does not cause photosensitivity.

A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)? a. Suprapubic pain b. Bladder distention c. Foul-smelling urine d. Costovertebral tenderness

ANS: DCostovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.DIF: Cognitive Level: Application REF: 1128

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states, a. "I can use vaginal sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: DVoiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is dis-couraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

A patient with nephrotic syndrome develops flank pain. The nurse will anticipate teaching the patient about treatment with a. antibiotics. b. anticoagulants. c. corticosteroids. d. antihypertensives.

B Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis.DIF: Cognitive Level: Application REF: 1133-1134

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care (select all that apply)? A. Administration of penicillin B. Tracheostomy for mechanical ventilation C. Administration of polyvalent antitoxin D. Teach correct processing of canned foods. E. Control of spasms with diazepam (Valium)

B, EControl of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation. Penicillin is administered for neurosyphilis. Use of polyvalent antitoxin and teaching the correct canning process is done for botulism.

What is the most common early symptom of a spinal cord tumor? A. Urinary incontinence B. Back pain that worsens with activity C. Paralysis below the level of involvement D. Impaired sensation of pain, temperature, and light touch

B. Back pain that worsens with activityThe most common early symptom of a spinal cord tumor outside the cord is pain in the back, with radicular pain simulating intercostal neuralgia, angina, or herpes zoster infection. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.

What is a common treatment for trigeminal neuralgia? A. Warm, moist compressions B. Carbamazepine (Tegretol) C. Ice packs applied intermittently D. Vitamin D

B. Carbamazepine (Tegretol)Carbamazepine (Tegretol) or oxcarbazepine (Trileptal) is the usual first-line therapy for trigeminal neuralgia. By acting on sodium channels, these drugs lengthen the time needed for neuron repolarization and decrease neuron firing. Some patients take megavitamins as an adjunct therapy. Temperature extremes are often a trigger for painful episodes.

What is the most common cause of botulism? A. Contamination from Escherichia coli from improper hand washing B. Contamination from spores from improper home canning C. Dairy foods kept at room temperature D. Eating undercooked poultry

B. Contamination from spores from improper home canningBotulism is caused by gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The organism is found in the soil and can grow in any food contaminated with the spores. Improper home canning of foods is often the cause. The other options are not related to botulism.

What is the main source of tetanus in the U.S. population? A. Tic bites B. Deep, penetrating wounds C. Unprotected sex D. Improperly prepared food

B. Deep, penetrating woundsTetanus results from a potent neurotoxin released by an anaerobic bacillus, Clostridium tetani. The spores enter the body through a traumatic or suppurative wound. The most common source in the United States is deep, penetrating wounds or intravenous drug use. The other options are not related to tetanus.

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for A. an aura or focal seizure. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations.

B. Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)? A. Stand erect with leg brace B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B. Spinal shock syndromeAbout 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

You suspect Bell's palsy in which patient? A. Unilateral facial droop with contralateral extremity weakness B. Sudden onset one-sided facial weakness with ear pain and vesicles C. Sharp, knife-like facial pain when eating hot or cold foods D. Inability to shrug the shoulders against resistance

B. Sudden onset one-sided facial weakness with ear pain and vesiclesBell's palsy is an acute, peripheral facial paresis of unknown cause without systemic effects. Facial droop is found in stroke. Sharp facial pain occurs with trigeminal neuralgia. An inability to shrug the shoulders describes pathology of cranial nerve XI.

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf.Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. Peripheral and periorbital edema is resolved. d. The antistreptolysin-O (ASO) titer is decreased.

C Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection.DIF: Cognitive Level: Application REF: 1131-1133

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness? a. Poor skin turgor b. High urine ketones c. Recent weight gain d. Low blood pressure

C The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.DIF: Cognitive Level: Comprehension REF: 1132-1134

A 50-year-old patient sustained a large, open wound. The patient indicates his last tetanus booster was 3 years earlier. What action do you anticipate? A. Administer tetanus and diphtheria toxoid (Td) booster. B. Administer tetanus immune globulin (TIg). C. Clean the wound with soap and water. D. Clean the wound with hydrogen peroxide.

C. Clean the wound with soap and water.Immediate, thorough cleansing of all wounds with soap and water is important in the prevention of tetanus. After the adult is immunized, a booster is given every 10 years. If an open wound occurs, a booster is given if the last one was 5 or more years earlier. Immune globulin is used if immunization was never provided. Hydrogen peroxide is not ordinarily used for wound cleansing.

What is the classic manifestation of a spinal cord tumor? A. Sudden onset of excruciating pain, worse at night B. Radiating pain down one leg C. Gradual onset of radicular pain, worse when lying down D. Positive Brudzinski's sign

C. Gradual onset of radicular pain, worse when lying downTumors are slow growing. The most common early symptom is pain in the back with radicular pain. The pain worsens with activity, coughing, straining, and lying down. Sudden onset of excruciating pain is not related to spinal cord tumors. Radiating pain down one leg is a classic characteristic of sciatic nerve pathology. A positive Brudzinski's sign is seen in meningitis.

What is characteristic of trigeminal neuralgia (tic douloureux)? A. Unilateral facial drooping B. Inability to hear whispered speech C. One-sided facial stabbing pain D. Attacks of severe dizziness

C. One-sided facial stabbing painTrigeminal neuralgia is usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve. Unilateral facial drooping is found in Bell's palsy or facial nerve pathology (cranial nerve [CN] VII). Inability to hear indicates pathology of the acoustic nerve (CN VIII). Attacks of severe dizziness do not occur in trigeminal neuralgia.

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface.A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? A. Call the physician. B. Check the patient's temperature. C. Take the patient's blood pressure. D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure.Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.

Which teaching helps to prevent botulism? A. Do not eat raw shellfish from contaminated water. B. Avoid consuming raw or undercooked eggs. C. Boil water for 10 minutes if unsure of the source. D. Discard any canned food with a swollen end.

D. Discard any canned food with a swollen end.A can's swollen ends may be caused by gases from C. botulinum and should be discarded. Improper food canning is a major cause of botulism. The other options are not related to botulism.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Impaired tissue integrity due to paralysis B. Impaired urinary elimination due to quadriplegia C. Ineffective coping due to the extent of trauma D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injuryMaintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination? A. Upper extremity weakness only B. Complete motor and sensory loss below C7 C. Loss of position sense and vibration in both lower extremities D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response? A. Increased vasomotor tone after the injury B. A temporary loss of sensation and flaccid paralysis below the level of injury C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilationeurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).

Which patient should be assigned to the experienced registered nurse on a neurologic floor? A. Patient with trigeminal neuralgia reporting facial pain rated at 10 B. Patient with Bell's palsy with unilateral facial droop C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency departmentThe patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.

What is the primary treatment for a primary neoplasm on the spine? A. High-dose oral corticosteroids B. Methylprednisolone IV C. Chemotherapy D. Surgery

D. SurgeryTreatment for most spinal cord tumors is surgical removal. Because autodestruction does not occur, recovery without residual problems is possible after the physical compression is relieved.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D. Throbbing headacheAutonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

What is a predominant causative trigger for the painful episodes in trigeminal neuralgia? A. Staphylococcus aureus cellulitis B. Misaligned bite of molar teeth C. Direct trauma to transmandibular joint D. Touching along the lower jaw

D. Touching along the lower jawTouch and tickle predominate as causative triggers. Others include chewing, tooth brushing, hot or cold blast of air on the face, washing the face, yawning, or talking. The other options are not significant causative factors.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient.When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

a, b, c, d, e Rationale: Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects.

Priority Decision: The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, what actions should the nurse take (select all that apply)? a. Loosen restrictive clothing. b. Turn the patient to the side. c. Protect the patient's head from injury. d. Place a padded tongue blade between the patient's teeth. e. Restrain the patient's extremities to prevent soft tissue and bone injury.

a, b, c. The focus is on maintaining a patent airway andpreventing patient injury. The nurse should not place objects in the patient's mouth or restrain the patient.

A patient is diagnosed with Bell's palsy. What information should the nurse teach the patient about Bell's palsy(select all that apply)? a. Bell's palsy affects the motor branches of the facial nerve. b. Antiseizure drugs are the drugs of choice for treatment of Bell's palsy. c. Nutrition and avoidance of hot foods or beverages are special needs of this patient. d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell's palsy. e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell's palsy. f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

a, d, e, f. Bell's palsy affects the motor branches of thefacial nerve. It is treated with corticosteroids, usuallyprednisone. Herpes simplex virus 1 may be a precipitatingfactor. Moist heat, gentle massage, electrical nervestimulation, and exercises are prescribed. Care must betaken to protect the eye with sunglasses, artificial tears orgel, and possibly taping the eyelid closed at night. Oralhygiene is important but avoidance of hot foods is notneeded.

Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical regionresulting in greater weakness in upper extremities than lower? a. Central cord syndrome b. Anterior cord syndrome c. Posterior cord syndrome d. Cauda equina and conus medullaris syndromes

a. In central cord syndrome, motor weakness and sensoryloss are present in both upper and lower extremities, withupper extremities affected more than lower extremities.

Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effectmust the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention

a. Spinal injury below C4 will result in diaphragmaticbreathing and usually hypoventilation from decreasedvital capacity and tidal volume from intercostal muscleimpairment. The nurse's priority actions will be tomonitor rate, rhythm, depth, and effort of breathing toobserve for changes from the baseline and identify theneed for ventilation assistance. Loss of all respiratorymuscle function occurs above C4 and the patient requiresmechanical ventilation to survive. Although the decreasedsympathetic nervous system response (from injuriesabove T6) and GI hypomotility (paralytic ileus and gastricdistention) will occur (with injuries above T5), they arenot the patient's initial priority needs.

Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can beprevented by immunization? a. Tetanus b. Botulism c. Neurosyphilis d. Systemic inflammatory response syndrome

a. Tetanus is transmitted through wound contamination,causes painful tonic spasms or seizures, and can beprevented with immunization.

Priority Decision: When planning care for the patient with trigeminal neuralgia, which patient outcome should thenurse set as the highest priority? a. Relief of pain b. Protection of the cornea c. Maintenance of nutrition d. Maintenance of positive body image

a. The pain of trigeminal neuralgia is excruciating andit may occur in clusters that continue for hours. Thecondition is considered benign with no major effects exceptthe pain. Corneal exposure is a problem in Bell's palsyor it may occur following surgery for the treatment oftrigeminal neuralgia. Maintenance of nutrition is importantbut not urgent because chewing may trigger trigeminalneuralgia and patients then avoid eating. Except duringan attack, there is no change in facial appearance in apatient with trigeminal neuralgia and body image is moredisturbed in response to the paralysis typical of Bell'spalsy.

What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache? a. Help the patient to examine lifestyle patterns and precipitating factors. b. Administer medications as ordered to relieve pain and promote relaxation. c. Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety. d. Support the patient's use of counseling or psychotherapy to enhance conflict resolution and stress reduction.

a. When the anxiety is related to a lack of knowledge about the etiology and treatment of a headache, helping the patient to identify stressful lifestyle patterns and other precipitating factors and ways of avoiding them are appropriate nursing interventions for the anxiety. Interventions that teach alternative therapies to supplement drug therapy also give the patient some control over pain and are appropriate teaching regarding treatment of the headache. The other interventions may help to reduce anxiety generally but they do not address the etiologic factor of the anxiety.

b, c, d, f. Cluster headaches have only alcohol as a dietarytrigger and have an abrupt onset lasting 5 minutes to 3 hourswith severe, sharp, penetrating pain. Cluster headaches maybe accompanied by unilateral ptosis, lacrimation, rhinitis,facial flushing or pallor and commonly recur several timeseach day for several weeks, with months or years betweenclustered attacks. Family history and nausea, vomiting,or irritability may be seen with migraine headaches.Bilateral pressure occurring between migraine headachesand intermittent occurrence over long periods of time arecharacteristics of tension-type headaches.

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. Whatfindings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation

b. At the C7 level, spinal shock is manifested bytetraplegia and sensory loss. The neurologic loss may betemporary or permanent. Paraplegia with sensory losswould occur at the level of T1. A hemiplegia occurs withcentral (brain) lesions affecting motor neurons and spastictetraplegia occurs when spinal shock resolves

The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which descriptionaccurately describes this syndrome? a. Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexicbowel and bladder b. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below thelevel of the lesion c. Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control andtemperature and pain sensation d. Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury

b. Brown-Séquard syndrome is characterized by ipsilateralloss of motor function and position and vibratory senseand vasomotor paralysis with contralateral loss of painand temperature sensation below the level of the injury.Damage to the most distal cord and nerve roots withflaccid paralysis of the lower limbs and areflexic boweland bladder is seen with cauda equine syndrome or conusmedullaris syndrome. Posterior cord syndrome is rare, withcord damage resulting in loss of proprioception below thelesion level but retention of motor control and temperatureand pain sensation. Anterior cord syndrome is often causedby flexion injury, with acute compression of the cordresulting in complete motor paralysis and loss of pain andtemperature sensation below the level of injury but touch,position, vibration, and motion remaining intact.

A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient? a. Hygiene care for an indwelling urinary catheter b. How to perform intermittent self-catheterization c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

b. Intermittent self-catheterization five to six times a day isthe recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is usedduring the acute phase to prevent overdistention of thebladder and surgical urinary diversions are used if urinarycomplications occur.

Which type of headache is suspected when the headaches are unilateral and throbbing, preceded by a prodrome ofphotophobia, and associated with a family history of this type of headache? a. Cluster b. Migraine c. Frontal-type d. Tension-type

A patient with a seizure disorder is being evaluated for surgical treatment of the seizures. The nurse recognizes that what is one of the requirements for surgical treatment? a. Identification of scar tissue that is able to be removed b. An adequate trial of drug therapy that had unsatisfactory results c. Development of toxic syndromes from long-term use of antiseizure drugs d. The presence of symptoms of cerebral degeneration from repeated seizures

b. Most patients with seizure disorders maintain seizure control with medications but if surgery is considered, three requirements must be met: the diagnosis of epilepsy must be confirmed, there must have been an adequate trial with drug therapy without satisfactory results, and the electroclinical syndrome must be defined. The focal point must be localized but the presence of scar tissue is not required.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is ofmost concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs

b. Neurogenic shock associated with cord injuriesabove the level of T6 greatly decreases the effect ofthe sympathetic nervous system and bradycardia andhypotension occur. A heart rate of 42 bpm is not adequateto meet the oxygen needs of the body. While low, theblood pressure is not at a critical point. The oxygensaturation is satisfactory and the motor and sensory lossesare expected.

During the diagnosis and long-term management of a seizure disorder, what should the nurse recognize as one of the major needs of the patient? a. Managing the complicated drug regimen of seizure control b. Coping with the effects of negative social attitudes toward epilepsy c. Adjusting to the very restricted lifestyle required by a diagnosis of epilepsy d. Learning to minimize the effect of the condition in order to obtain employment

b. One of the most common complications of a seizure disorder is the effect it has on the patient's lifestyle. This is because of the social stigma attached to seizures, which causes patients to hide their diagnosis and to prefer not to be identified as having epilepsy. Medication regimens usually require only once- or twice-daily dosing and the major restrictions of lifestyle usually involve driving and high-risk environments. Job discrimination against the handicapped is prevented by federal and state laws and patients only need to identify their disease in case of medical emergencies.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will resultfrom the injury. What is the best response by the nurse? a. "You will have more normal function when spinal shock resolves and the reflex arc returns." b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved." c. "When your condition is more stable, MRI will be done to reveal the extent of the cord damage." d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what thecomplete effect will be."

b. Until the edema and necrosis at the site of the injuryare resolved in 72 hours to 1 week after the injury, itis not possible to determine how much cord damage ispresent from the initial injury, how much secondary injuryoccurred, or how much the cord was damaged by edemathat extended above the level of the original injury. Thereturn of reflexes signals only the end of spinal shock andthe reflexes may be inappropriate and excessive, causingspasms that complicate rehabilitation.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he isrecovering some function. What is the nurse's best response to the patient? a. "It is really still too soon to know if you will have a return of function." b. "That could be a really positive finding. Can you show me the movement?" c. "That's wonderful. We will start exercising your legs more frequently now." d. "I'm sorry but the movement is only a reflex and does not indicate normal function."

b. When spinal shock ends, reflex movement and spasmswill occur, which may be mistaken for return of function;however, with the resolution of edema, some normalfunction may also occur. It is important when movementoccurs to determine whether the movement is voluntaryand can be consciously controlled, which would indicatesome return of function.

The nurse cares for a 63-year-old woman taking prednisone (Deltasone) and acyclovir (Zovirax) for Bell's palsy. It is most important for the nurse to follow up on which patient statement? A. "I can take both medications with food or milk." B. "I will take these medications for 2 to 3 months." C. "I can take acetaminophen with the prescribed medications." D. "Chances of a full recovery are good if I take the medications."

bPrednisone and acyclovir will usually be prescribed for 10 days. Prednisone will be tapered over the last 4 days of treatment. Oral prednisone and acyclovir may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 2 to 3 months. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. There are no serious drug interactions among prednisone, acyclovir, and acetaminophen.

The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures (select all that apply)? a. Formerly known as grand mal seizure b. Often accompanied by incontinence or tongue or cheek biting c. Psychomotor seizures with repetitive behaviors and lip smacking d. Altered memory, sexual sensations, and distortions of visual or auditory sensations e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities f. Often involves behavioral, emotional, and cognitive functions with altered consciousness

c, d, f. Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral, emotional, or cognitive experiences without memory of what was done during the seizure. In generalized tonic-clonic seizures (previously known as grand mal seizures) there is loss of consciousness and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek biting may also occur.

What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia? a. Carry out all hygiene and oral care for the patient. b. Use conversation to distract the patient from pain. c. Maintain a quiet, comfortable, draft-free environment. d. Have the patient examine the mouth after each meal for residual food.

c. Because attacks of trigeminal neuralgia may beprecipitated by hot or cold air movement on the face,jarring movements, or talking, the environment should beof moderate temperature and free of drafts and patientsshould not be expected to converse during the acute period.Patients often prefer to carry out their own care becausethey are afraid someone else may inadvertently injurethem or precipitate an attack. The nurse should stress thatoral hygiene be performed because patients often avoidit but residual food in the mouth after eating occurs morefrequently with Bell's palsy.

Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient hasa poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? a. Institute frequent turning and repositioning. b. Use tracheal suctioning to remove secretions. c. Assess lung sounds and respiratory rate and depth. d. Prepare the patient for endotracheal intubation and mechanical ventilation.

c. Because pneumonia and atelectasis are potentialproblems related to ineffective coughing and the loss ofintercostal and abdominal muscle function, the nurseshould assess the patient's breath sounds and respiratoryfunction to determine whether secretions are being retainedor whether there is progression of respiratory impairment.Suctioning is not indicated unless lung sounds indicateretained secretions. Position changes will help to mobilizesecretions. Intubation and mechanical ventilation are usedif the patient becomes exhausted from labored breathing orif arterial blood gases (ABGs) deteriorate.

A patient at the clinic for a routine health examination mentions that she is exhausted because her legs bother her so much at night that she cannot sleep. The nurse questions the patient further about her leg symptoms with what knowledge about restless legs syndrome? a. The condition can be readily diagnosed with EMG. b. Other more serious nervous system dysfunctions may be present. c. Dopaminergic agents are often effective in managing the symptoms. d. Symptoms can be controlled by vigorous exercise of the legs during the day.

c. Restless legs syndrome that is not related to other pathologic processes, such as diabetes mellitus or rheumatic disorders, may be caused by a dysfunction in the basal ganglia circuits that use the neurotransmitter dopamine, which controls movements. Dopamine precursors and dopamine agonists, such as those used for parkinsonism, are effective in managing sensory and motor symptoms. Polysomnography studies during sleep are the only tests that have diagnostic value and although exercise should be encouraged, excessive leg exercise does not have an effect on the symptoms.

The nurse teaches the patient taking antiseizure drugs that this method is most commonly used to measure compliance and monitor for toxicity. a. A daily seizure log b. Urine testing for drug levels c. Blood testing for drug levels d. Monthly electroencephalography (EEG)

c. Serum levels of antiseizure drugs are monitored regularly to maintain therapeutic levels of the drug, above which patients are likely to experience toxic effects and below which seizures are likely to occur. Many newer drugs do not require drug level monitoring because of large therapeutic ranges. A daily seizure log and urine testing for drug levels will not measure compliance or monitor for toxicity. EEGs have limited value in diagnosis of seizures and even less value in monitoring seizure control.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge? a. Rehabilitation measures cannot be initiated until spinal shock has resolved. b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomicfunctions are not affected.

c. Spinal shock occurs in about half of all people withacute spinal cord injury. In spinal shock, the entirecord below the level of the lesion fails to function,resulting in a flaccid paralysis and hypomotility of mostprocesses without any reflex activity. Return of reflexactivity, although hyperreflexive and spastic, signalsthe end of spinal shock. Rehabilitation activities arenot contraindicated during spinal shock and should beinstituted if the patient's cardiopulmonary status is stable.Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension,peripheral vasodilation, and decreased cardiac output(CO). Sympathetic function is impaired below the levelof the injury because sympathetic nerves leave thespinal cord at the thoracic and lumbar areas and cranialparasympathetic nerves predominate in control overrespirations, heart, and all vessels and organs below theinjury, which includes autonomic functions.

Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injuryshould the nurse expect to be used? a. Kinetic beds b. Hard cervical collar c. Skeletal traction with skull tongs d. Sternal-occipital-mandibular immobilizer brace

c. The development of better surgical stabilization hasmade surgery the more frequent treatment of cervicalinjuries. However, when surgery cannot be done,skeletal traction with the use of Crutchfield, Vinke, orother types of skull tongs is required to immobilizethe cervical vertebrae, even if a fracture has notoccurred. Hard cervical collars or a sternal-occipitalmandibularimmobilizer brace may be used after cervicalstabilization surgery or for minor injuries or stabilizationduring emergency transport of the patient. Sandbagsmay also be used temporarily to stabilize the neckduring insertion of tongs or during diagnostic testingimmediately following the injury. Special turning orkinetic beds may be used to turn and mobilize patientswho are in cervical traction.

What causes an initial incomplete spinal cord injury to result in complete cord damage? a. Edematous compression of the cord above the level of the injury b. Continued trauma to the cord resulting from damage to stabilizing ligaments c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

c. The primary injury of the spinal cord rarely affectsthe entire cord but the pathophysiology of secondaryinjury may result in damage that is the same asmechanical severance of the cord. Complete corddissolution occurs through autodestruction of the cord byhemorrhage, edema, and the presence of metabolites andnorepinephrine, resulting in anoxia and infarction of thecord. Edema resulting from the inflammatory responsemay compress the spinal cord as well as increase thedamage as it extends above and below the injury site.

Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell that lasts for a few seconds? a. Atonic b. Simple focal c. Typical absence d. Atypical absence

c. The typical absence seizure is also known as petit maland the child has staring spells that last for a few seconds. Atonic seizures occur when the patient falls from loss of muscle tone accompanied by brief unconsciousness. Simple focal seizures have focal motor, sensory, or autonomic symptoms related to the area of the brain involved without loss of consciousness. Staring spells in atypical absence seizures last longer than those in typical absence seizures and are accompanied by peculiar behavior during the seizure or confusion after the seizure.

Delegation Decision: The nurse is preparing to admit a newly diagnosed patient experiencing tonic-clonic seizures. What could the nurse delegate to unlicensed assistive personnel (UAP)? a. Complete the admission assessment. b. Explain the call system to the patient. c. Obtain the suction equipment from the supply cabinet. d. Place a padded tongue blade on the wall above the patient's bed.

c. The unlicensed assistive personnel (UAP) is able to obtain equipment from the supply cabinet or department. The RN may need to provide a list of necessary equipment and should set up the equipment and ensure proper functioning. The RN is responsible for the initial history and assessment as well as teaching the patient about the room's call system. Padded tongue blades are no longer used and no effort should be made to place anything in the patient's mouth during a seizure.

The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patientto have? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes

c. With the injury at T4, the highest-level realistic goal forthis patient is to be able to be independent in self-care andwheelchair use because arm function will not be affected.Indoor mobility in a manual wheelchair will be achievablebut it is not the highest-level goal. Ambulating withcrutches and leg braces can be achieved only by patientswith injuries in T6-12 area. Independent ambulation withshort leg braces and canes could occur for a patient withan L3-4 injury. (See Table 61-4.)

What is one indication for early surgical therapy of the patient with a spinal cord injury? a. There is incomplete cord lesion involvement. b. The ligaments that support the spine are torn. c. A high cervical injury causes loss of respiratory function. d. Evidence of continued compression of the cord is apparent.

d. Although surgical treatment of spinal cord injuries oftendepends on the preference of the health care provider,surgery is usually indicated when there is continuedcompression of the cord by extrinsic forces or when thereis evidence of cord compression. Other indications mayinclude progressive neurologic deficit, compound fractureof the vertebra, bony fragments, and penetrating woundsof the cord.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what shouldthe nurse anticipate that the patient will need? a. IV fluids b. Tube feedings c. Parenteral nutrition d. Nasogastric suctioning

d. During the first 2 to 3 days after a spinal cord injury,paralytic ileus may occur and nasogastric suction must beused to remove secretions and gas from the GI tract untilperistalsis resumes. IV fluids are used to maintain fluidbalance but do not specifically relate to paralytic ileus.Tube feedings would be used only for patients who havedifficulty swallowing and not until peristalsis returns.Parenteral nutrition would be used only if the paralyticileus was unusually prolonged.

How do generalized seizures differ from focal seizures? a. Focal seizures are confined to one side of the brain and remain focal in nature. b. Generalized seizures result in loss of consciousness whereas focal seizures do not. c. Generalized seizures result in temporary residual deficits during the postictal phase. d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.

d. Generalized seizures have bilateral synchronous epileptic discharge affecting the entire brain at onset of the seizure. Loss of consciousness is also characteristic but many focal seizures also include an altered consciousness. Focal seizures begin in one side of the brain but may spread to involve the entire brain. Focal seizures that start with a local focus and spread to the entire brain, causing a secondary generalized seizure, are associated with a transient residual neurologic deficit postictally known as Todd's paralysis.

What is the most important method of diagnosing functional headaches? a. CT scan b. Electromyography (EMG) c. Cerebral blood flow studies d. Thorough history of the headache

d. The primary way to diagnose and differentiate between headaches is with a careful history of the headaches, requiring assessment of specific details related to the headache. Electromyelography (EMG) may reveal contraction of the neck, scalp, or facial muscles in tensiontype headaches but this is not seen in all patients. CT scans and cerebral angiography are used to rule out organic causes of the headaches.

Which type of seizure is most likely to cause death for the patient? a. Subclinical seizures b. Myoclonic seizures c. Psychogenic seizures d. Tonic-clonic status epilepticus

d. Tonic-clonic status epilepticus is most dangerous because the continuous seizing can cause respiratory insufficiency, hypoxemia, cardiac dysrhythmia, hyperthermia, and systemic acidosis, which can all be fatal. Subclinical seizures may occur in a patient who is sedated, so there is no physical movement. Myoclonic seizures may occur in clusters and have a sudden, excessive jerk of the body that may hurl the person to the ground. Psychogenic seizures are psychiatric in origin and diagnosed with videoelectroencephalography (EEG) monitoring. They occur in patients with a history of emotional abuse or a specific traumatic episode.

What drug therapy is included for acute migraine and cluster headaches that appears to alter the pathophysiologic process for these headaches? a. β-Adrenergic blockers such as propranolol (Inderal) b. Serotonin antagonists such as methysergide (Sansert) c. Tricyclic antidepressants such as amitriptyline (Elavil) d. Specific serotonin receptor agonists such as sumatriptan (Imitrex)

d. Triptans (sumatriptan [Imitrex]) affect selected serotonin receptors that decrease neurogenic inflammation of the cerebral blood vessels and produce vasoconstriction. Both migraine headaches and cluster headaches appear to be related to vasodilation of cranial vessels and drugs that cause vasoconstriction are useful in treatment of migraine and cluster headaches. Methysergide blocks serotonin receptors in the central and peripheral nervous systems and is used for prevention of migraine and cluster headaches. β adrenergic blockers and tricyclic antidepressants are used prophylactically for migraine headaches but are not effective for cluster headaches.

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