Med Surg Exam 3 spring 2021

Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes to prevent harm? - "Check your hands and feet weekly for chronic excessive sweating." - "Change positions slowly when moving from sitting to standing." - "Avoid drinking caffeine or caffeinated beverages." - "Be sure to take your blood pressure drug daily."

"Change positions slowly when moving from sitting to standing."Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults.Although taking blood pressure medication daily is important, it does not prevent orthostatic hypotension and in fact, may make orthostatic hypotension worse. Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy. Avoiding caffeine is no longer a recommended action.

Which statement by a client indicates to the nurse correct understanding of what to do when the sensations of hunger and shakiness occur? "I will eat three graham crackers." "I will drink a glass of water." "I will sit down and rest." "I will give myself a dose of glucagon."

"I will eat three graham crackers." Feeling hungry and shaky are symptoms of mild hypoglycemia. Correct understanding of what the client needs to do when these symptoms occur is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.

What is the nurse's best response to a client newly diagnosed with type 1 diabetes who asks why insulin is only given by injection and not as an oral drug?

"Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.

What action will the nurse advise to prevent harm for a client with diabetes who has a 3-cm callus on the ball of the right foot? - "Make an appointment with your podiatrist as soon as possible." - "Make an appointment with a pedicurist and have them cut or file off the callus." - "Soak your feet nightly in warm water and peel of a little of the callus every day." - "Apply an over-the-counter callus-dissolving pad and follow the package directions."

"Make an appointment with your podiatrist as soon as possible." The client with diabetes is taught to see his or her diabetes health care provider or a podiatrist for calluses, corns, or any other foot lesion and never to self-treat such problems. The risk for development of an ongoing injury with chronic infection is very high could lead to eventual amputation. "

What is the nurse's best response when family members of a client with hyperthyroidism express concern about the client's frequent mood swings?

"Mood swings are common should diminish with treatment." Telling the family that the client's mood swings should diminish over time with treatment provides information to the family, as well as reassurance that this behavior is expected.

Which specific action is a priority for the nurse to teach a client with diabetes who has peripheral neuropathy to prevent harm? "Wear a medical alert bracelet." "Never go barefoot." "Never reuse insulin syringes." "Drink at least 3 L of fluids daily."

"Never go barefoot."All the actions are important for the client with diabetes to perform for safety and to prevent a variety of complications. However, the most important action to prevent harm from peripheral neuropathy is to never go barefoot and wear shoes and slippers with firm soles.

Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? - "The abdominal site is best because it is closest to the pancreas." - "I can reach my thigh best, so I will use different areas of the same thigh." - "If I change my injection site from the thigh to an arm, the inulin absorption may be different." - "By rotating sites within one area, my chance of having skin changes is less."

"The abdominal site is best because it is closest to the pancreas." The abdominal site has the fastest and most consistent rate of absorption because of the blood vessels in the area and not because of its proximity to the pancreas. The other statements demonstrate correct understanding about injection site selection and rotation.

What is the nurse's best response to a client newly diagnosed with diabetes who asks why he is always so thirsty?

"The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." The high blood glucose levels that are present, because movement of glucose into cells is impaired, increase the osmolarity of the blood. The increased osmolarity stimulates the osmoreceptors in the hypothalamus, which triggers the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.

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

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

How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible? - "You can have a beer with a meal if you test yourself for hypoglycemia an hour later." - "You can have a beer with a meal if you test yourself for hyperglycemia an hour later." - "There are nonalcoholic beers available that you can substitute for a regular beer." - "If you gave up dessert, you can still have one beer."

"You can have a beer with a meal if you test yourself for hypoglycemia an hour later." Alcohol consumption contributes to hypoglycemia. This risk is reduced if the alcohol is consumed with or shortly after a meal. The client is instructed to check blood glucose levels about an hour after alcohol is consumed to determine if either more food is needed or if insulin dosage needs to be adjusted.

What is the nurse's best response to a client with type 2 diabetes controlled with metformin who asks why now that he is recovering from surgery, is he prescribed to receive insulin therapy for a few days? - "Your insurance doesn't permit metformin to be used during hospitalization." - "Your presurgical testing indicates that you now have type 1 diabetes and require daily insulin." - "You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." - "You must take insulin from now on because the surgery has aggravated the intensity of your diabetes."

"You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two."The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.

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

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

Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? - A 55-year-old client who has hypoglycemic unawareness - An 80-year-old client with type 2 diabetes mellitus - A 45-year-old client with type 1 diabetes mellitus - A 75-year-old client whose blood glucose levels show little variation

- A 75-year-old client whose blood glucose levels show little variation Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Clients are taught that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness are warned to not ever use alternate sites for SMBG.

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

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

Monitor for drug toxicity when patients are taking medications for PD, especially levodopa combinations. ______?________ and _____________?_________________ are the most common indicators of toxicity.

- Delirium - Decreased drug effectiveness

Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "dawn phenomenon" to achieve better control? - Eat a bedtime snack containing equal amounts of protein and carbohydrates." - Avoid eating any carbohydrate with your evening meal." - Take your evening insulin dose right before going to bed instead of at supper time." - Inject the insulin into your arm rather than into the abdomen around the navel."

Take your evening insulin dose right before going to bed instead of at supper time." A client with "dawn phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia that results from a nighttime release of adrenal hormones causing blood glucose elevations at about 5 to 6 a.m. It is managed by providing more insulin for the overnight period (e.g., giving the evening dose of intermediate-acting insulin at 10 p.m. instead of with the evening meal).Bedtime snacks are needed for "Somogyi phenomenon" that is morning hyperglycemia caused by the counterregulatory response to nighttime hypoglycemia. Changing the injection site would not prevent morning hyperglycemia. Not eating any carbohydrate with a meal is more likely to cause severe hypoglycemia during the night and is dangerous.

Why is a goiter often present in clients who have Graves disease?

The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).

Which new-onset symptoms will the nurse instruct a client with diabetes who is prescribed to take the sodium-glucose cotransport inhibitor, empagliflozin, to report to the diabetes health care provider to prevent harm? (Select all that apply.) Muscle weakness and dizziness on standing Redness and tenderness at the injection site Rapid weight gain and shortness of breath Redness and tenderness of the perineum Sensations of hunger, tremors, sweating, and confusion Pain and burning on urination

- Muscle weakness and dizziness on standing - Redness & tenderness of the perineum - Sensations of hunger, tremors, sweating, & confusion - Pain & burning on urination Drugs from the lower blood glucose levels by preventing kidney reabsorption of glucose and sodium that was filtered from the blood into the urine. This filtered glucose is excreted in the urine rather than moved back into the blood. Hypoglycemia (symptoms of hunger, tremors, sweating, confusion) is possible as is dehydration with excessive sodium loss (muscle weakness and orthostatic hypotension with dizziness on standing). The excess glucose in the urine increases the risk for urinary tract infections with pain and burning on urination. These drugs increase the risk for Fournier gangrene with perineal fasciitis, which has early symptoms of redness and tenderness of the perineal skin.The drug is taken orally and not by injection. It is not associated with heart failure that may manifest with symptoms of rapid weight gain and shortness of breath.

Which assessment is a priority for the nurse to make when a client with diabetic ketoacidosis (DKA) who is being monitored while receiving an insulin infusion begins to show an irregular heart beat with inverted T-waves? - Rate of IV infusion - Urine output - Potassium level - Breath sounds

- Potassium level After DKA therapy starts, serum potassium levels drop quickly. An ECG showing an irregular pattern and inverted T-waves is most likely related to low potassium levels (hyperkalemia). Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the cardiac irregularities is essential.The cardiac issues are not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. The client with DKA is not at risk for hypoventilation or poor gas exchange. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.

How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 82 mg/dL (mmol/L) and an A1c of 5.9%? - The values indicate that the client has poorly managed his or her disease. - The values indicate that the client has managed his or her disease well. - The client's glucose control for the past 24 hours has been good but the overall control is poor. - The client's glucose control for the past 24 hours has been poor but the overall control is good.

- The values indicate that the client has managed his or her disease well. Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client's FBG is well within the normal range.A1c provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client's A1c level is within the desirable range, indicating good long-term glucose control as well as short-term control.

A client newly diagnosed with type 1 diabetes says she is not ready to learn everything about diabetes control right now. Which information has the greatest priority for the nurse to teach this client and her family for now to prevent harm? (Select all that apply) - Causes of type 1 diabetes - What to do when ill? - Symptoms and treatment of hypoglycemia - Insulin administration - Dietary control of blood glucose - Importance of regular exercise

- What to do when I am ill? - Symptoms & treatment of hypoglycemia - Insulin administration The priority information for safety and preventing harm that the nurse needs to teach the client and family about diabetes are: Symptoms and management of hypoglycemia because it is a life-threatening condition.Proper insulin administration is essential for the management of type 1 diabetes and to prevent death.Knowing what to do when ill is critical information because illness will require changes in the client's day-to-day use of insulin and may need contact with the client's diabetes health care provider to prevent harm.The causes of diabetes, dietary control, and exercise are less important for immediate safety and can be taught at another time.

At which time will the nurse plan to monitor for hypoglycemia in a client with type 1 diabetes received regular insulin at 7:00 a.m.? 7:30 am 7:30 pm 11:00 am 2:00 pm

11:00 a.m. Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. The other options for peak times for regular insulin are incorrect.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." A 30 year old with type 1 diabetes who is reporting thirst. A 40 year old with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L). A 50 year old with type 2 diabetes with a blood pressure of 150/90 mm Hg.

A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 50 year old taking repaglinide who has nausea and back pain. A 55 year old taking pioglitazone who has bilateral ankle swelling. A 45 year old taking metformin who has abdominal cramps. A 40 year old taking glyburide who is dizzy and sweaty.

A 45 year old taking metformin who has abdominal cramps. The nurse needs to first assess the client taking glyburide who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.

Which statement made by a client about thyroid hormone replacement therapy (HRT) indicates to the nurse that further teaching is needed? A. "If I continue to lose weight, I may need an increased dose." B. "I will have more energy with this medication." C. "If I often am constipated and feel tired, I may need an increased dose." D. "I will take the medication every morning."

A. "If I continue to lose weight, I may need an increased dose." The statement, "If I continue to lose weight, I may need an increased dose," indicates a need for further teaching. Weight loss indicates a need for a decreased dose, not an increased dose.One of the symptoms of hypothyroidism is lack of energy. Thyroid replacement therapy would cause the client to have more energy. The correct time to take thyroid replacement therapy is in the morning. Frequent constipation and continuing to feel tired are indications that the dose may need to be increased.

The nurse is teaching assistive personnel (AP) about how to communicate with an older client who has receptive aphasia. Which instruction would the nurse include? A. "Use simple short sentences and one-step commands." B. "Work with the speech-language pathologist for suggestions." C. "Write sentences or words on a white board for the client." D. "Speak loudly to ensure that the client can hear."

A. "Use simple short sentences and one-step commands." Receptive aphasia is an inability to understand words or sentences, whether it is verbal or written. Therefore, using short simple, one-step sentences and commands is the best instruction to provide AP. Unless the client has a heading deficit, there is no need to talk loudly.

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

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

Which trends in serum electrolyte values will the nurse expect to find in a client who has untreated hypoparathyroidism? A. Below normal calcium levels; above normal phosphorus levels B. Below normal calcium levels; below normal phosphorus levels C. Above normal calcium levels; above normal phosphorus levels D. Above normal calcium levels; below normal phosphorus levels

A. Below normal calcium levels; above normal phosphorus levels With hypoparathyroidism, the lack of parathyroid hormone (PTH) decreases serum calcium levels by increasing kidney calcium excretion and inhibiting calcium absorption from the GI tract. Low levels of calcium cause a corresponding increase in serum phosphorus levels because calcium and phosphorus exist in a balanced reciprocal relationship in which a decrease in one always causes an increase in the other.

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

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

The nurse is monitoring a client admitted with a neurological injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately? A. Decreased level of consciousness (LOC) B. Blood pressure of 140/88 C. Temperature of 100 degrees D. Apical pulse of 90 & regular

A. Decreased level of consciousness (LOC)

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

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

Which signs and symptoms in a client who has hyperthyroidism indicate to the nurse possible progression to a thyroid storm? (Select all that apply.) A. Elevated temperature B. Tachycardia C. Somnolence D. Elevated systolic blood pressure E. Abdominal pain & nausea F. Slow respiratory rate

A. Elevated temperature B. Tachycardia D. Elevated systolic blood pressure E. Abdominal pain & nausea

The nurse is teaching a group of older adults about stroke prevention. Which risk factors for stroke would the nurse include? (Select all that apply.) A. High blood pressure B. Previous stroke or TIA Smoking C. Use of oral contraceptives D. Female gender E. Smoking

A. High blood pressure B. Previous stroke or TIA C. Use of oral contraceptives E. Smoking Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

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

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

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What would the nurse suspect that the client is most likely experiencing? A. Transient ischemic attack B. Thrombotic stroke C. Embolic stroke D. Hemorrhagic stroke

Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

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

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

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

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

The nurse is caring for a client who is diagnosed with middle stage (moderate) Alzheimer disease. What assessment findings would the nurse expect? (Select all that apply.) Agnosia Mild impaired cognition Sleeping problems Seizures Wandering Psychoses

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

The nurse is planning health teaching for a client who had a transient ischemic attack (TIA) to help prevent a major stroke. What teaching would the nurse include? (Select all that apply.) A. "Seek a smoking cessation program, if needed." B. "Increase physical activity by exercising regularly." C. "Monitor BP frequently to assess control." D. "Take you prescribed antiplatelet agent as prescribed." E. "If diabetic, work to achieve glucose control as needed." F. "Eat a heart-healthy diet every day if possible."

All of these instructions are important in helping to prevent a major stroke for a client who had a TIA.

The nurse is assessing a client who was diagnosed with Alzheimer disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document? Aphasia Apraxia Anomia Agnosia

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

Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." and has vital signs of: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air? - Administering oxygen - Connecting a cardiac monitor - Assessing arterial blood gas (ABG) values - Assessing blood glucose level

Assessing blood glucose level The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis (DKA).Based on the oxygen saturation, oxygen administration is not indicated. The diagnosis of DKA does not require ABGs. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A. AVPU B. FAST C. KIND D. PQRST

B. "FAST" The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.

Which statement made by the client alerts the nurse to the possibility of hypothyroidism? A. "I seem to feel the heat more than other people." B. "I am always tired, even when I get 10 or 12 hours of sleep." C. "Food just doesn't taste good without a lot of salt." D. "My grandmother had thyroid problems."

B. "I am always tired, even when I get 10 or 12 hours of sleep." Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance. Clients with hypothyroidism have a slow metabolism and have difficulty keeping warm. Salt craving is not a symptom of hypothyroidism.

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

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

With which client will the nurse be aware of an increased risk for hypoparathyroidism? A. A 28-year-old woman with pregnancy-induced hypertension B. A 35-year-old woman who had radiation therapy for Graves disease C. A 50-year-old man starting on insulin therapy for type 2 diabetes mellitus D. A 55-year-old man with moderate heart failure after myocardial infarction

B. A 35-year-old woman who had radiation therapy for Graves disease. Hypoparathyroidism is a relatively rare disorder. It is most often caused by treatment for hyperthyroidism that resulted in injury to the parathyroid glands. None of the other client health problems increase the risk for development of hypoparathyroidism.

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

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

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

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

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

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

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

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

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

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

A nurse is assessing a client with a suspected diagnosis of MS. Which assessment findings will the nurse expect? (Select all that apply). a. Resting tremors b. Memory loss c. Muscle spasticity d. Fatigue e. Diplopia f. Dysarthria

b. Memory loss c. Muscle spasticity d. Fatigue e. Diplopia f. Dysarthria All of these except for "resting tremors" are correct. - Intention tremors (tremor when performing an activity) are a key feature of MS. - MS is a chronic disease caused by immune, genetic, and/or infectious factors that affects the myelin and nerve fibers of the brain & spinal cord. The cause of MS is very complex, although changes in immunity are the most likely etiology.

Which statements regarding hyperthyroidism are accurate? (Select all that apply.) A. Has a sudden onset of symptoms B. Is much more common among women than among men C. Produces symptoms of a hypermetabolic state D. Most common form is Graves disease E. Can be diagnosed by the presence of goiter F. Often occurs weeks after exposure to ionizing radiation

B. Is much more common among women than among men C. Produces symptoms of a hypermetabolic state D. Most common form is Graves disease Hyperthyroidism increases the metabolism and function of all systems. The most common cause of hyperthyroidism is Graves disease, which is an autoimmune disorder, often occurring after an episode of thyroid inflammation leading to the production of autoantibodies (thyroid-stimulating immunoglobulins [TSIs]) that attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland. The increased stimulation of TSH receptors greatly increases thyroid hormone production. All thyroid problems are from five to ten more common among women than men.The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. Exposure to ionizing radiation can induce hypothyroidism, not hyperthyroidism.

Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.) A. Goiter B. Nonpitting edema of hands & feet C. Warm, moist skin D. Decreased deep tendon reflexes E. Agitation & inability to sleep F. Pulse rate below 60 beats/ min

B. Nonpitting edema of hands & feet D. Decreased deep tendon reflexes F. Pulse rate below 60 beats/ min Hypothyroidism slows the metabolism and function of all systems and the ones that are usually first noticed and can lead to life-threatening complications are the cardiac and central nervous systems. Thus, the heart rate is usually slower than 60 beats/min, and the deep tendon reflexes are decreased. Metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells, which increase the mucus and water, forming cellular edema that is nonpitting.The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. The skin reflects the client's overall decreased metabolism and is cool and dry.

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

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

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

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

Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)? A. "Increase the amount of fiber in your diet to prevent the side effect of constipation." B. "Stop this drug immediately if you discover you are pregnant." C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." D. "If you miss a dose, double your next day's dose."

C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the primary health care provider. Fiber greatly interferes with the drug's absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day's dose.

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

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

Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment? A. "Luckily, I have my own bathroom, so I won't be exposing the rest of my family to radiation." B. "If this treatment works, maybe I will stop sweating all the time." C. "It will be great to lose my "bug-eyed" appearance." D. "I hope I don't gain too much weight when my thyroid function is normal."

C. "It will be great to lose my "bug-eyed" appearance."Although successful radioactive iodine (RAI) therapy for Graves disease results in reducing most physical symptoms, the exophthalmia does not respond to this therapy. Other measures, such as drug therapy targeted to the exophthalmos and not the hyperthyroidism and surgery to remove tissue from behind the eye, are needed to improve the eye appearance. All other client statements demonstrate accurate understanding of the disorder and its treatment.

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

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

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

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

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What would the nurse do first? A. perform a focused neurologic assessment B. Position client in a seated positon C. Assess airway, breathing, circulation D. Call the primary HCP

C. Assess airway, breathing, circulation When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team (RRT), not the primary health care provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for the RRT to assess and begin treatment. This does not need to be a seated position.

Which assessment finding in a client who had a parathyroidectomy yesterday indicates to the nurse that immediate action is needed? A. Hypoactive bowel sounds B. Apical pulse of 92 beats/ min C. Bilateral leg muscle twitching D. Dry mouth

C. Bilateral leg muscle twitching Clients are at risk for hypocalcemia and seizures after removal of the parathyroid glands. Muscle twitching is an indication of hypocalcemia and requires assessment and intervention. The other findings are abnormal but not associated with complications from the surgery.

Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.) A. Hypertonic saline B. Furosemide C. Calcium gluconate D. Oxygen E. Suction F. Emergency tracheotomy kit

C. Calcium gluconate D. Oxygen E. Suction F. Emergency tracheotomy kit Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client's bedside because of the risk for increased secretions.Furosemide is a diuretic used to treat hypercalcemia associated with hyperparathyroidism. However, hypocalcemia from inadvertent parathyroid removal during thyroidectomy is the greater concern. Hypertonic saline is not necessary for this client. This client is not expected to have hyponatremia after surgery.

Which type of drug therapy will the nurse prepare to teach about to a client who has mild hyperparathyroidism? A. Antipyretics B. Opioid analgesics C. Furosemide diuretics D. Calcium supplements

C. Furosemide diuretics High ceiling or loop diuretics, such as furosemide increase calcium excretion and are used to manage calcium levels in clients who have mild hyperparathyroidism. Antipyretics are not routinely prescribed because fever is not associated with the disorder. Opioid analgesics are used only when a problem causing acute pain is present and not for typical management of mild hyperparathyroidism. Calcium supplements are contraindicated because hyperparathyroidism results in chronic hypercalcemia.

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

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

A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)? A. Place the client in Trendelenburg position B. Suction the client frequently & as needed C. Maintain neutral head position D. Assess for Grey Turner sign

C. Maintain neutral head position. To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.

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

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

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

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

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

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

Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min? A. Increasing the IV infusion rate B. Initiating the Rapid Response Team C. Assessing temperature D. Applying oxygen by mask

D. Applying oxygen by mask The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.

The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client's temperature is 99.6° F (37.6° C). After notifying the primary health care provider, what is the nurse's best next action? A. Administering acetaminophen B. Observing the presence of chills C. Initiating the Rapid Response Team D. Assessing cardiac status

D. Assessing cardiac status Graves disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client's cardiac status as atrial fibrillation or other dysrhythmias may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias.Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time as no instability has been noted. Unlike with infection, temperature elevations in a client with hyperthyroidism are not associated with chills.

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

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

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How would the nurse help the client compensate? A. Approach the client on the affected side B. Place objects in the client's field of vision C. Encourage turning the head from side to side. D. Cover the affected eye, if possible.

D. Cover the affected eye, if possible. The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch may help reduce diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

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

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

For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider? A. calf muscle cramping B. runny nose C. Anorexia D. Hand tremors

D. Hand tremors Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and muscle cramping are neither side effects of the drug nor indications of toxicity.

A client has been admitted with a diagnosis of stroke. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Quick to anger & frustration B. Inability to discriminate words C. Aphasia & cautiousness D. Impulsiveness & smiling

D. Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.

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

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

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A. Administering morphine for pain B. Assessing the wound dressing for bleeding C. Hyperextending the neck D. Monitoring oxygen saturation

D. Monitoring oxygen saturation Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea.Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck should not be extended or hyperextended because this position puts too much tension on the incision.

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

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

Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective? A. Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels B. Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels C. Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.

What is the nurse's best action when finding that a client who has had diabetes for 15 years has decreased sensory perception in both feet? - Testing the sensory perception of the client's hands - Examining both feet for indications of injury - Explaining to the client that peripheral neuropathy is now present - Documenting the finding as the only action

Examining both feet for indications of injury When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.

What is the nurse's best response when a client with diabetes who is being treated for hypoglycemic asks why people without diabetes don't become severely hypoglycemic even after fasting for 8 hours?

In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). Glucagon is a counter-regulatory hormone secreted by pancreatic alpha cells when blood glucose levels are low, as they would be during an 8 hour fast. The body's metabolic rate does decrease during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are then released into the blood to maintain blood glucose levels and prevent hypoglycemia. Although proteins can be broken down and converted to glucose, they are not converted to glycogen. Fat break down through lipolysis can provide fatty acids for fuel but this is not glucose and lipolysis does not occur until all stored glycogen is used.

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

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

Which client assessment finding indicates to the nurse the possible presence of diabetic autonomic neuropathy? Loss of sensation in both feet Hyperglycemia Intermittent constipation Increased thirst

Intermittent constipation Autonomic neuropathy can affect the entire GI system. The most common GI problem from diabetic automonic neuropathy is sluggish intestinal movement and chronic intermittent constipation.Loss of sensation in the feet is peripheral neuropathy, not autonomic neuropathy. Hyperglycemia is not related to any type of neuropathy. Increased thirst is related to hyperglycemia and increased blood osmolarity, not neuropathy.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times B. Reposition the client every 3 to 4 hours C. Avoid the use of antiembolism stockings D. Administer pain medication before deep-breathing exercises

Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area.Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Intracranial pressure monitor B. Mini-mental state examination (MMSE) C. National Institutes of Health Stroke Scale (NIHSS) D. Glasgow Coma Score (GCS)

National Institutes of Health Stroke Scale (NIHSS)The nurse uses the NIHSS tool to perform a focused neurologic assessment. Primary health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a nonspecific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

A client completed an alteplase infusion following a thrombotic stroke. What nursing action is appropriate? A. Insert an indwelling catheter B. Perform frequent neurologic assessments C. Notify radiology to schedule an MRI D. Administer an antiplatelet agent.

Perform frequent neurologic assessments. After administering an alteplase infusion, the nurse performs a focused neurologic assessment, including vital signs, every 15 to 30 minutes, depending on agency protocol and the client's condition. Antiplatelet therapy is not started for at least 24 hours after infusion. A urinary catheter or other invasive tube can cause bleeding and should be avoided. The client would have a CT angiogram or perfusion scan before antiplatelet therapy is initiated.

Which action is appropriate for the nurse to delegate to the assistive personnel (AP) when caring for clients with diabetes? - Monitoring a client who reports palpitations and anxiety - Verifying the infusion rate on a continuous infusion insulin pump - Performing a blood glucose check on a client who requires insulin - Assessing a client who reports tremors and irritability

Performing a blood glucose check on a client who requires insulin Performing bedside glucose monitoring is a task that may be delegated to an AP who has been educated in this technique because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for AP. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for AP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.

Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys? - Protein in the urine during a random urinalysis. - Glucose in the urine during hyperglycemia - Ketone bodies in the urine during acidosis - WBCs in the urine during a random urinalysis

Protein in the urine during a random urinalysis Urine should not contain protein and the presence of proteinuria in a client with marks the beginning of renal problems known as diabetic nephropathy, that progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.

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

Stooped posture Masklike facial expression Drooling at times Shuffled gait Dysarthria Muscle rigidity All of these signs and symptoms commonly occur in clients who have PD. Four cardinal symptoms of PD: tremor, muscle rigidity, bradykinesia (or akinesia), & postural instability. Changes in cognition (dementia, psychoses) are late-stage symptoms.

Early indicators of MS

vision, mobility, & sensory perception changes

Which factor is most important for the nurse to assess before providing instruction to a client newly diagnosed with diabetes about the disease and its management? - Current energy level and rest patterns - Sexual orientation - Current lifestyle for diet and exercise - Education and literacy levels

Education and literacy levels The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.