Hurst Misc. Q Bank Questions

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select All That Apply 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications.

2, 3, 5 2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin. 1. Incorrect: The spleen, not the liver, removes old RBCs from the body. 4. Incorrect: The exocrine function of the pancreas releases digestive enzymes into the small intestine. If you missed this question, go to page 138* (144) of your student book to study this content. *Page numbers will depend on what version of student book applies.

Male Self-Catherization procedure teaching:

Correct Order: First, clean the meatus. Second, lubricate several inches of the tip of the catheter. Third, hold your penis on both sides just behind the head. Next, insert the catheter six inches into the urethra, using a steady gentle pressure. Fifth, use gentle but firm pressure on the catheter until the muscle relaxes and the catheter becomes easier to advance. It will be necessary to pass the catheter another two or three inches before it enters the bladder. Sixth, allow urine to drain completely.

The client is being admitted for a myocardial infarction (MI). Which assessment finding is expected? 1. Reports of nausea and vomiting 2. Elevated temperature higher than 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two aspirin tablets. 4. Myoglobin will be negative.

1. Correct: Pain with MI may have associated symptoms that include nausea, vomiting, diaphoresis, palpitations, and shortness of breath. 2. Incorrect: Temperature as high as 102 degrees F (38.89 degrees C) may occur for several days after infarction. Temperature higher than this would not be expected. 3. Incorrect: Aspirin is given to prevent platelet aggregation and does not relieve chest pain from an MI. Nitroglycerin and morphine will help with pain associated with an MI. 4. Incorrect: A negative myoglobin will rule out an MI.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? You answered this questionCorrectly 1. Regular rhythm 2. Rate of 101-200 3. P wave normal 4. P-R interval not measurable 5. QRS complex normal

1., 2., 3. & 5. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. The P-wave is normal in a sinus rhythm. Sinus rhythms have a normal QRS complex. 4. Incorrect: P-R interval is not measurable in atrial flutter, atrial fib, PVCs, V tach or V fib.

A client is admitted with a diagnosis of disorganized schizophrenia. What characteristic should the nurse anticipate being manifested? 1. Evidence of loose associations 2. Use of neologisms and clang associations 3. Unpredictable or inappropriate emotional responses 4. Presence of stupor or presence of waxy flexibility 5. Suspiciousness and delusions of persecution 6. Flat or inappropriate affect

1., 2., 3., & 6. Correct: Disorganized schizophrenia is characterized by social withdrawal and disorganization in speech, behavior, and emotional expression. One of the characteristics that you may see in a client with disorganized schizophrenia includes evidence of loose associations in which the client rapidly shifts topics when speaking without any logical connection between the thoughts. Clients with disorganized schizophrenia may also use neologisms which are made up words that only have meaning to them, or they may have clang associations where they use words that typically rhyme but have no connection in meaning. Unpredictable or inappropriate emotional responses are common in clients with disorganized schizophrenia. They have a lack of impulse control and exhibit behaviors that are bizarre or lack purpose. Even activities of daily living can be difficult or impossible for the client to complete. These clients often exhibit flat or inappropriate affect. Their facial expressions, voice tone, and mannerisms may show little or no emotion or have responses that are inappropriate to the situation. 4. Incorrect: Presence of stupor or presence of waxy flexibility are characteristics of catatonic schizophrenia. There can be a total lack of psychomotor activity or you may see the client assume a position that is maintained until moved by another person. Once moved, the client then maintains that set position. 5. Incorrect: Suspiciousness and delusions of persecution are classic signs of paranoid schizophrenia. Disorganized schizophrenia is one of the subtypes of schizophrenia. With disorganized schizophrenia, you may see various behaviors including regression, social withdrawal, bizarre behavior, and nonsensical speech. You do not typically see hallucinations and delusions in disorganized schizophrenia as frequently seen with paranoid schizophrenia, but they can occur. So what do you think happens to their speech? Since they have trouble concentrating and staying focused on a thought, their speech becomes disorganized as well. They may have incoherent speech, give unrelated answers, say things that are illogical, and have rapid shifts of topics (loose associations). Neologisms, which are made up words that only have meaning to them, and clang associations, where they use words that typically rhyme but have no connection in meaning, are common disturbances in speech. Disorganized schizophrenia is characterized by difficulty carrying out goal-directed behavior. The clients may not be able to complete a simple task. They may not be able to carry out the activities of daily living like bathing, dressing, and brushing their teeth. The emotional impact may be evident by bizarre, unpredictable, or inappropriate responses. The client may have difficulty or an inability to control impulses. Disorganized schizophrenia is characterized by a flat or inappropriate affect. The way a person responds emotionally or expresses emotions is referred to their affect. With a flat affect, little or no emotion is evident. This is reflected by a lack of facial expression, monotone voice, and dull mannerisms. However, these clients can shift to an inappropriate affect where they exhibit emotional responses that are inappropriate to the situation, such as laughing when they are told of a sad situation. These clients often do not make direct eye contact and their facial expressions are dulled.

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? You answered this questionCorrectly 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia

Chronic renal failure requires bilateral kidney failure. The kidneys filter out wastes (toxins) and excess fluid from the body through urine. The kidneys also produce erythropoietin which stimulates red blood cell production. When chronic renal failure reaches an advanced stage, dangerous levels of fluid, electrolytes, and toxins can build up in the body. Erythropoietin production drops causing anemia. So the nurse needs to worry about fluid volume excess, hyperkalemia, anemia and decreasing LOC. So what are pertinent signs that a client is in chronic renal failure? Remember to look at each option as a true/false statement. Option 1: True. When toxins build up in the body and the client becomes anemic, the client is tired and fatigues easily. Option 2: True. Anorexia occurs because of the buildup of fluid within organs and from the uremic toxins building up in the blood.. Option 3: False. The client may have an uremic frost. This is crystallized urea deposits in the skin that develops in renal failure. Dark skin pigmentation is a sign of Addison's disease. Option 4: True. The client will develop fluid volume excess when in chronic renal failure. As the vascular volume increases past what it can hold, then fluid will begin to leak out into the tissue (3rd spacing). This leads to edematous extremities. Option 5: True. As kidney function worsens, the kidneys may be unable to remove enough potassium from the body. Also, eating too many foods high in potassium can cause hyperkalemia in chronic renal failure.

NS @ 50mL/hr =

KVO keep vein open rate

The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats

1, 3 and 4. CORRECT: Symptoms of benign prostatic hyperplasia are very similar to those of a urinary tract infection. As the prostate enlarges and presses against the bladder wall, it becomes more difficult for a client to start and maintain a stream of urine, or even to completely empty the bladder. Medications prescribed for this disorder are meant to shrink the prostate, allowing urine to flow easily when voiding. When the medications are ineffective, the client again experiences the original symptoms such as bladder pain, urinary frequency and a tendency to continue 'dribbling' urine after the bladder is emptied. The client may then need a different medication or a change in the dose currently prescribed. 2. INCORRECT: The symptoms of fever with chills are related to infection rather than benign prostatic hyperplasia. Although untreated BPH may lead to a urinary infection because of retained urine, these two symptoms do not relate directly to this prostate disorder. 5. INCORRECT: Nighttime sweats are not associated with benign prostatic hyperplasia. Nighttime sweats can be associated with tuberculosis.

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply 1. Drink between meals.2. Reduce intake of carbohydrates.3. Eat small, frequent meals daily.4. Sit semi-recumbent for meals.5. Remain upright for one hour after eating.6. Lie down on left side after eating.

1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the processing of food.

Which interventions should a nurse discuss with a client for primary prevention of skin cancer from exposure to ultraviolet light? 1. Use sunscreen when outdoors. 2. Stay in the shade when outdoors. 3. Wear wide brimmed hats when outdoors. 4. Examine skin every 3 months for changes. 5. Have an annual skin assessment by a dermatologist.

1., 2. & 3. Correct: Using sunscreen, staying in shaded areas, and wearing wide brimmed hats are effective interventions to prevent skin cancer. 4. Incorrect: Examine your whole body monthly for possible changes that may be precancerous or cancerous lesions. Early detection is considered secondary prevention. 5. Incorrect: Assessment by a dermatologist is not a primary prevention strategy. Early diagnosis is considered secondary prevention.

The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is prescribed. In reviewing the client's history, which information is of concern to the nurse? 1. Coronary artery stent 2. Cardiac pacemaker 3. Prescribed glimepiride every morning 4. Extreme obesity 5. History of working with metal fragments

1., 2., 4. & 5. Correct: With a coronary artery stent the magnet in the MRI may exert too much of a pull on the stent and cause damage. If a client with a cardiac pacemaker has an MRI, the pacemaker is turned off and the client could die. Extreme obesity, usually over 300 pounds is contraindicated. Magnetic substances in the body may become dislodged by the magnet, so history of working with metal fragments must be reviewed. 3. Incorrect: The client does not need to be NPO or have any modifications of their medications, so hypoglycemia is not a concern for MRI.

A school nurse is concerned that a teenager may have bulimia. What assessment findings would substantiate this belief? 1. Discolored teeth 2. Calluses on knuckles 3. Underweight 4. Dehydration 5. Hoarseness

1., 2., 4., & 5. Correct: Discolored teeth occur from exposure to stomach acid when throwing up. The teeth may look yellow, ragged, or translucent. Calluses or scars on the knuckles or hands from sticking fingers down the throat to induce vomiting. Dehydration can occur from excessive vomiting and laxative or diuretic abuse. Hoarseness and chronic sore throat can occur due to stomach acid getting in the throat when vomiting. 3. Incorrect: The client is not underweight, but has a changing weight. Most are within normal weight range but may become slightly underweight or slightly overweight.

A client arrives in the emergency department with suspected methamphetamine intoxication. The client is extremely agitated with violent outbursts, hypertensive, and tachycardic. What treatment should the nurse anticipate for this client? 1. Droperidol 2. Lorazepam 3. Methylphenidate 4. Dexmethylphenidate 5. Labetalol 6. Nitroprusside

1., 2., 5., & 6 Correct: What cues did you pick up in the stem? This client is agitated, violent, hypertensive and tachycardic. Would the heart tolerate this for a long time period? No! This is a situation that should be managed quickly. So, how can we best manage this client with methamphetamine intoxication? Let's consider the extreme agitation and violent outbursts. What would be effective in reducing these behaviors? You may be thinking of Inapsine (droperidol) as an antiemetic agent, but are you aware that it is used to produce marked tranquilization, sedation, and a reduction in anxiety? In clients with methamphetamine intoxication, droperidol can produce more rapid and significant sedation than Ativan (lorazepam), but both droperidol and lorazepam can be useful in these clients to not only reduce the agitation and produce sedation, but they can also help reduce the pulse and systolic blood pressure. If the hypertension and tachycardia continues despite the use of droperidol and/or lorazepam, the client may be given a beta-blocker and vasodilator to manage these symptoms. Labetalol is the preferred beta-blocker because of its combined anti-alpha-adrenergic and anti-beta-adrenergic effects. Vasodilators, such as nitroprusside, may be used to help lower the blood pressure. 3. Incorrect: Ritalin (methylphenidate) is a CNS stimulant. Do we need to cause CNS stimulation in this client? No!! This would be dangerous to give a client who is already extremely agitated, has hypertension and tachycardia, and is at risk of having seizures. 4. Incorrect: Focalin (dexmethylphenidate) is also a CNS stimulant and would not be appropriate treatment for this client with hypertension and tachycardia. We would never want to give the client something that would worsen the symptoms!

A nurse is assigned a client who is one day post thyroidectomy. While taking the blood pressure, the client's hand starts to tremble. On auscultation of the heart, the nurse notes an arrhythmia. What actions should the nurse take? You answered this questionCorrectly 1. Pad the side rails 2. Monitor potassium level 3. Take blood pressure in opposite arm 4. Place trach set at bedside 5. Check for airway patency

1., 4., & 5. Correct: During the thyroidectomy the parathyroid(s) could have been removed causing a decrease in the calcium level and could progress to a seizure and laryngospasms. Padding the side rails is a safety precaution for seizures. The nurse places a trach set at the bedside in case of laryngospasms. Check for airway patency as the esophagus is a smooth muscle. Think muscles with calcium and with hypocalcemia remember not enough sedative. 2. Incorrect: I am worried about calcium with the parathyroid, not potassium. The NCLEX Lady thought you would see arrhythmia and say potassium, but calcium can cause heart problems as well. 3. Incorrect: This action is not needed. This would only provide you with the same response and delay treatment.

A client of Islamic faith has died and the family wishes to uphold the basic Islamic beliefs for end of life care. What intervention would be appropriate at this time? 1. Upon death, close the eyelids and mouth and pull a covering over the body. 2. Begin necessary preparations for the body to be cremated as soon as possible. 3. Move the body immediately to the morgue for transport to funeral home. 4. Allow someone in the family or mosque to bathe and wrap body in white cloth. 5. Stand quietly or provide privacy as final prayers are offered by family. 6. Place the head of the deceased facing Mecca.

1., 4., 5., and 6. Correct: Based on basic beliefs of the Islamic faith, upon death, the eyes and mouth should be closed. The body should initially be covered with a sheet or similar covering. A practice known as the ghusl is performed which involves the washing of the deceased person's body. This is typically done by an adult family member of the same sex of the deceased, and then the body is enshrouded (wrapped), typically in plain, white cloth. The nurse should show respect to the family by either providing quiet presence as final prayers are offered or by allowing the family to have privacy during this final time with their family member who has died. A practice that may be performed before and/or after the time of death is positioning the head so that it faces Mecca. This may involve moving the bed to where the head faces Mecca or it may involve turning the head to the right side. 2. Incorrect: Cremation is strictly forbidden in the Islamic faith. 3. Incorrect: Islamic practices call for burying the body as soon as possible, which eliminates the need for embalming, unless required by law. However, taking the body to the morgue immediately would not allow the family time to perform the washing and enshrouding of the body and would be disrespectful to both the deceased and the family. In addition, autopsies are not usually allowed unless there is foul play suspected, in which permission may be granted to perform the autopsy. The body of the deceased should be disturbed as little as possible after death.

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? Exhibit Correct! 1. Cirrhosis2. Pancreatitis3. Peptic ulcer4. Ulcerative colitis

2 Pancreatitis These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever. What are the classic s/s of cirrhosis that are different from pancreatitis? Firm, nodular liver, dyspepsia, change in bowel habits, splenomegaly, acites. Peptic ulcers typically do not present with severe pain, but with a burning pain in the mid-epigastric area and back. Dyspepsia is common as well, but no bruising around the flank area or umbilicus. Ulcerative colitis presents with diarrhea, rectal bleeding, vomiting, weight loss, cramping, rebound tenderness and fever.

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2., & 5. Correct: Remember that aldosterone is a mineralocorticoid, which causes the client to retain sodium and water. Retaining sodium and water will cause the client's weight to increase. Also remember, any sudden gain in weight is due to water retention. Too much aldosterone makes you retain too much sodium and water and lose potassium. Normal potassium is 3.5-5.0 mEq/L, so a lowering of potassium could indicate high levels of aldosterone.1. Incorrect: Oily skin would be seen with an increase in sex hormones such as testosterone and estrogen. Oily skin is not common with mineralocorticoids like aldosterone.3. Incorrect: Too many glucocorticoids will cause the breakdown of protein and fat but muscular weakness and increased fatigue is seen with too little mineralocorticoids.4. Incorrect: Too many glucocorticoids will inhibit insulin, causing the serum blood glucose level to go up. Normal blood glucose is 70-110.

After completing the initial morning assessment of a client, the nurse notes that a dose of intranasal desmopressin is to be administered. What action is most important for the nurse to take? Exhibit shows signs of FVE -- 1. Measure urine osmolality. 2. Hold desmopressin dose. 3. Administer acetaminophen for headache. 4. Instruct client on intranasal administration of desmopressin.

2. Correct: This client is in fluid volume excess, so the desmopressin needs to be held. The nurse needs to discuss the dose with the primary healthcare provider. 1. Incorrect: Urine osmolality can be assessed but it is not the priority. There are lots of data findings indicating that the client is in a fluid volume excess. 3. Incorrect: There is nothing wrong with giving the client acetaminophen for reports of a headache, but it is not the most important action for the nurse to take. 4. Incorrect: Teaching is an important nursing task. However, it is not the most important task now. Teaching can be done later. here are lots of hints in this question and exhibits. Did you see them all? The client is on desmopressin, which is used for DI. Diabetes insipidus occurs when you do not have enough antidiuretic hormone (ADH). So, you lose too much water, right? Yes. Desmopressin is a synthetic ADH, to make the client retain water. So, what are you worried about with desmopressin? Fluid volume excess. Here are hints that should have led you to the fact that the client is retaining too much fluid: Drowsiness, mild headache, dry mucous membranes, 1+/4+ pitting edema noted at ankles (1+ = 0-1/4-inch indentation), pulses bilaterally 3+/4+ (3+ = increased pulse requiring moderate pressure to obliterate). Vital signs and weight progressively increasing. Remember a rapid weight gain is fluid, not fat. What about UOP? It has dropped over 24 hours. So, there are your signs and symptoms for the development of fluid volume excess. One of the exhibits gave you all the information you need for desmopressin. If you read it, you would have noticed the signs/symptoms of toxicity: drowsiness, headache, weight gain, and difficulty urinating. The guide also said to use cautiously in hypertension. Recommended treatment was to decrease the dose and, if severe, administer furosemide. Decreasing the dose was not an option, but holding the dose was. So, this is the priority action that should be taken by the nurse.

What medications would the nurse anticipate for the treatment of hyperthyroidism? You answered this questionCorrectly 1. Levothyroxine 2. Methimazole 3. Propranolol 4. Iodine compounds 5. Calcitonin

2., 3., & 4. Correct: Methimazole is correct because it decreases the production of thyroid hormones. It is an antithyroid drug and it is used to "stun" the thyroid pre-operatively. It makes the thyroid "freak out" and stop producing hormones temporarily. Propanolol is correct because it is a beta blocker and beta blockers decrease the heart rate and decrease anxiety. Why is this important? Because the heart rate and anxiety are going to be increased in the hyperthyroid client. Iodine compounds like Lugol's solution® are correct because these decrease the size and vascularity of the thyroid gland. Do you think this might be important pre-operatively?YES, to decrease the likelihood of bleeding/hemorrhage. And we also, just learned that pharmacologic doses of iodine will also do what? That's right, large doses will decrease thyroid hormone production for a few weeks. So that's two reasons we might use an Iodine compound for Hyperthyroidism. 1. Incorrect: We are not going to give levothyroxine, that's just going to make the problem worse! Because what is levothyroxine? That's right it's the synthetic form of T4. 5. Incorrect: What about calcitonin? It is a thyroid hormone too! They don't need more! They are hyperthyroid! So False.

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration

2., 3., & 5. Correct: Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and the chest wall; heart sounds are lowered and distant. A pericardial friction rub is a classic symptom of acute pericarditis. Chest pain is the most common symptoms of pericarditis, and is aggravated by deep inspiration, coughing, position change, and swallowing. 1. Incorrect: Petechiae on the trunk, conjunctiva, and mucous membranes are indicative of endocarditis. 4. Incorrect: Pulsus paradoxus is an exaggerated decrease of systolic blood pressure during inspiration exceeding 12 mm Hg. It is the hallmark of cardiac tamponade. Signs and symptoms include sharp, stabbing chest pain over the center or left side of the chest, chest pain may intensify when inhale deeply; trouble breathing when leaning back; pulse and BP difference in upper extremities; palpitations; weakness; coughing; hoarseness; dysphagia; cyanosis; distended neck veins; anxiety and fatigue; and low-grade fever. You may hear a pericardial friction rub, muffled heart sounds, or extra sounds because of the pressure being placed on the heart.

A client with a long standing history of diabetes presents to the emergency department (ED) with a serum blood sugar of 400 mg/dL (22.19 mmol/L). What lab data for this client are consistent with diabetic ketoacidosis (DKA)? You answered this questionCorrectly 1. Serum sodium 140 mEq/L 2. Ketonuria 3. Serum potassium 5.3 mEq/L 4. PaCO2 52 5. pH 7.30

2., 3., & 5. Correct: Normally, no ketones are found in the urine. Ketonuria is associated with poorly controlled diabetes that results in hyperglycemia and breakdown of body fat and protein. Remember dilute makes numbers go down. The potassium will be elevated because insulin is needed to move potassium out of the blood and into the cell. With DKA, the client is in metabolic acidosis, so the pH will be low. 1. Incorrect: Sodium is essential for maintaining a stable blood pressure and fluid balance in the body. High blood sugar causes excessive urination with loss of body water and sodium. This can cause dehydration and low blood pressure. When the body needs to restore water to the bloodstream, it does so by pulling it from other tissues. This influx of water into the bloodstream may cause blood sodium to be further diluted. A low sodium level can cause symptoms of dizziness, fatigue, general weakness and, if severe, mental confusion or seizures. Insulin and intravenous fluids containing sodium chloride are used to treat the sodium deficit caused by DKA. This sodium level is normal (135-145). 4. Incorrect: The client will have an increased respiratory rate. So the PaCO2 will go down. This PaCO2 is high, so that correlates with hypoventilation.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

2., 3., & 5. Correct: The nurse needs to wear sterile gloves when cleaning the wound. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. 1. Incorrect: Sterile supplies should be used with this procedure because the client is at risk for infection and gangrene. Gauze and salve should be used instead of a wash cloth. 4. Incorrect: Before you start, make sure the cleansing solution is at room temperature. Do not heat in the microwave. It could scald the client!

Which nursing strategies are appropriate while caring for a client with anorexia nervosa? 1. Encourage client to cook for others. 2. Restrict use of bathroom for 30 minutes after meals. 3. When meal is over, remove food and discuss client's intake. 4. Monitor food intake. 5. Sit with client during meals.

2., 4., & 5. Correct: This client will go to the bathroom and vomit what little food they take in. As a nurse you need to monitor intake to keep the client alive. If the client does not eat, then nourishment must be given intravenously or via a nasogastric tube. Lastly, providing companionship during meal time is a good thing. Attention to the social aspects of eating is important. 1. Incorrect: This does not address the client's condition. 3. Incorrect: The nurse should never focus on the food and the amount consumed. You want no discussion about the food. Food is not the problem.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? You answered this question Correctly 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first. 1. Incorrect: Administration of 500 mL of fluid over one hour is possible if the client were in shock. The stem of the question, however, does not indicate this client is in shock. 2. Incorrect: Monitoring BUN and creatinine does not help identify diabetes insipidus. 4. Incorrect: Decadron can cause fluid retention, not increased urinary output.

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? 1. The drainage is continuous but slow. 2. The drainage is cloudy and dark yellow. 3. The drainage is bright red. 4. No drainage of urine or irrigation solution is noted.

3. Correct: Indicates blood and increasing the flow helps flush the catheter. 1. Incorrect: Continuous irrigation causes continuous drainage. 2. Incorrect: The color is noted and color from pink to amber is expected. 4. Incorrect: Indicates a possible obstruction.

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? Correct! Choose One1. "Octreotide is an antibiotic given to decrease the risk of developing an infection."2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence."3. "Octreotide helps eliminate ammonia from the body."4. "This medication lowers the pressure in the liver, so bleeding stops."

4. Correct: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop. 1. Incorrect:Octreotide is not an antibiotic. 2. Incorrect: You might be thinking of sucralfate, which forms a barrier over an ulcer so acid can't get on the ulcer. 3. Incorrect: No, lactulose decreases ammonia. If you missed this question go to page 141* (147) of your student book to study this content.