Med Surg Hesi Quiz

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? Diabetes mellitus. Hypothyroidism. Parkinson's disease. Recurring pneumonia.

A) Diabetes mellitus. A history of diabetes mellitus poses the greatest risk for developing a CVA (A). (B, C, and D) may place the client at some risk due to immobility, but do not present a risk as great as (A).

The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2° F. Which intervention should the nurse implement? Document the temperature reading on the vital sign graphic sheet. Report the temperature to the healthcare provider immediately. Instruct the UAP to take the client's temperature again in 30 minutes. Advise the UAP to assist the client in returning to her bed.

Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2° F (orally) is a common finding in elderly clients, so the nurse should document the findings (A) and continue with the plan of care. (B, C, and D) are not indicated unless the temperature falls below 97° F or if other symptoms occur.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? Jewish European ancestry. H. pylori bowel infection. Family history of irritable bowel syndrome. Age between 25 and 55 years.

Jewish European ancestry Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry (A). H. pylori is associated with stomach inflammation and ulcer development (B). Irritable bowel syndrome (C) does not progress to inflammatory bowel disease. UC has a peak between the ages of 15 and 25 years, then a second peak between 55 and 65 years, not (D).

A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? What dose of medication are you taking? Are you eating foods rich in potassium? Have you lost weight recently? At what time do you take your medication?

D) At what time do you take your medication? The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to insomnia.

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client have her own teeth or dentures?" take aspirin and if so, how much?" take nitroglycerin?" take digitalis?"

D) take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant.

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? Keep the client on bed rest for eight hours. Check vital signs every 15 minutes for two hours. Allow the client nothing by mouth until the gag reflex returns. Encourage fluid intake to promote elimination of the contrast media.

Allow the client nothing by mouth until the gag reflex returns. The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns (C) to prevent aspiration from any oral intake or secretions. (A, B, and D) are not indicated after bronchoscopy.

The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? Loss of short-term memory, facial tics and grimaces, and constant writhing movements. Shuffling gait, masklike facial expression, and tremors of the head. Extreme muscular weakness, easy fatigability, and ptosis. Numbness of the extremities, loss of balance, and visual disturbances.

B) Shuffling gait, masklike facial expression, and tremors of the head. (B) are common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis.

Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system? Pupil constriction. Increased heart rate. Bronchial constriction. Decreased blood pressure.

B) Increased heart rate. Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a flight-or-fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system.

An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? Begin wearing the aids in quiet environments to experiment with adjustments. Wear the hearing aids for an hour a day at first, gradually increasing the time. Keep the volume on low until the conditions with noises are audible. Use one hearing aid until comfortable, then add the second aid.

Begin wearing the aids in quiet environments to experiment with adjustments. Initially, the use of hearing aids should be restricted to quiet situations in the home (A). As adjustments occur, the client should gradually be exposed to conditions with background noise and the outdoors. Time restriction (B) is not necessary. (C and D) do not help the client adjust as well as gradually introducing various sound conditions. Category: Medical-Surgical

Which healthcare practice is most important for the nurse to teach a postmenopausal client? Wear layers of clothes if experiencing hot flashes. Use a water-soluble lubricant for vaginal dryness. Consume adequate foods rich in calcium. Participate in stimulating mental exercises.

C) Consume adequate foods rich in calcium. Bone density loss associated with osteoporosis increases at a more rapid rate when estrogen levels begin to fall, so the most important healthcare practice during menopause is ensuring an adequate calcium (C) intake to help maintain bone density and prevent osteoporosis. Although practices such as (A and B) may reduce some of the discomforts for a postmenopausal female, calcium intake is more important than comfort measures. Although social and mental exercises stimulate thought, there is no scientific evidence that mental exercises (D) prevent dementia or common forgetfulness associated with reduced hormonal levels.

Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious in an elderly person because elderly persons usually live alone and cannot summon help when symptoms appear. elderly persons are more likely to eat high-fat diets which make them susceptible to heart disease. cardiac symptoms, such as confusion, are more difficult to recognize in the elderly. elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls.

D) elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls. Cardiac output is decreased with aging (D). Because of loss of contractility and elasticity, blood flow is decreased and tachycardia is poorly tolerated. Therefore, if an elderly person experiences dysrhythmia (tachycardia or bradycardia), further compromising their cardiac output, they are more likely to experience syncope, falls, transient ischemic attacks, and possibly dementia. Most elderly persons do not eat high-fat diets (B) and most are not confused (C). Although many elderly persons do live alone, inability to summon help (A) cannot be assumed.

The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? Extend the left arm laterally with the left palm upward. Extend the arm, dorsiflex the wrist, and extend the fingers. Extend the arms and hold this position for 30 seconds. Extend arms with both legs adducted to shoulder width.

Extend the arm, dorsiflex the wrist, and extend the fingers Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position (B). (A, C, and D) do not illicit axterixis.

A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance.

Gastrointestinal disturbance Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning (D). It is recommended that this drug be taken with food to avoid gastrointestinal upset. Naproxen (Naprosyn) does not cause sensitivity to sunlight (A), muscle fasciculations (B), or urinary frequency (C).

A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic.

Give a sublingual nitroglycerin tablet. After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin (C) to dilate the coronary arteries and increase myocardial oxygenation. Then, (A, B, and D) are implemented.

In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone.

Left lateral, supine, brief periods on the right side, and prone After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position (D) to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulating. (A, B, and C) do not maintain the client for optimal functioning.

The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest.

Pathologic fracture of two ribs on the right chest The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurence of two right-sided ribs with pathological fractures resulting without evidence of trauma (D) is related to radiation damage. The heart (B), esophagus (C), and larger bronchi (A) are not usually in the radiation path.

A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? Refer for further diagnostic evaluation. Determine exposure of others to the tuberculosis. Begin anti-tubercular drug therapy. Quarantine or isolate to control communicability.

Refer for further diagnostic evaluation The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in a homeless environment. Although productive prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be implemented (A). Although exposed populations (B) should be identified, differential diagnosis for this client should be determined. A small proportion of persons (about 10%) with LTBI will develop active TB, which requires drug therapy (C). LTBI (usually in the lungs) is a dormant form that neither causes disease nor is communicable, so (D) may not be indicated. Category: Medical-Surgical

When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching? Recommend that the client carry suction equipment at all times. Instruct the client to have writing materials with him at all times. Tell the client to carry a medic alert card stating that he is a total neck breather. Tell the client not to travel alone.

Tell the client to carry a medic alert card stating that he is a total neck breather. It is imperative that total neck breathers carry a medic alert notice (C) so that if they have a cardiac arrest, mouth-to-neck breathing can be done. Mouth-to-mouth resuscitation will not help them. They do not need to carry (A) nor refrain from (D). There are many alternative means of communication for clients who have had a laryngectomy; depending on (B) is probably the least effective. How do you know he can read and write?

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? Frequent urinary tract infections. Inability to get pregnant. Premenstrual syndrome. Chronic use of laxatives.

inability to get pregnant. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility.

Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) pH 6. Nitrate small. Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015.

pH 6. Sugar negative. Bilirubin negative. Specific gravity 1.015. Correct selections are (A, D, E, and F). (A) is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis (D and E). Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection (B and C), and enlarged prostate, these are indicative of pathology which should be treated.

Which client should the nurse assess first? A 27-year-old complaining of severe back pain. A 63-year-old complaining of foot and ankle pain. A 49-year-old with pancreatitis complaining of unrelenting abdominal pain. A 55-year-old newly admitted client complaining of jaw pain and indigestion.

A 55-year-old newly admitted client complaining of jaw pain and indigestion. The 55-year-old client (D) should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury. While severe back pain (A) may indicate a dissecting abdominal aortic aneurysm, a 27-year-old client is less likely to be experiencing cardiac syndrome. The client with foot and ankle pain (B) is not experiencing a life-threatening condition. The client with pancreatitis (C) requires pain management but this is not as high a priority as (D).

A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? Impaired communication related to paralysis of skeletal muscles. High risk for infection related to increased intracranial pressure. Potential for injury related to impaired lung expansion. Social isolation related to inability to communicate.

A) Impaired communication related to paralysis of skeletal muscles. To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C).

. The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? Loss of thirst, weight gain. Dependent edema, fever. Polydipsia, polyuria. Hypernatremia, tachypnea.

A) Loss of thirst, weight gain. SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D).

Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? Newly retracted nipple. A thickened area where the skin folds under the breast. Whitish nipple discharge. Tender lumpiness noted bilaterally throughout the breasts.

A) Newly retracted nipple. A newly retracted nipple (A), compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up. The inframammary ridge (B) is a normal anatomic finding. Up to 80% of women may experience an intermittent nipple discharge (C), especially related to recent stimulation, and in most cases, nipple discharge is not related to malignancy. (D) is a classic finding for fibrocystic breast disease, a benign condition.

Small bowel obstruction is a condition characterized by which finding? Severe fluid and electrolyte imbalances. Metabolic acidosis. Ribbon-like stools. Intermittent lower abdominal cramping.

A) Severe fluid and electrolyte imbalances. Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances (A). (B, C, and D) are findings associated with large bowel obstruction.

Which action should the nurse implement when implementing a physical assessment of an older client? Avoid unnecessary touching while interacting with the client. Apply additional pressure to palpate the hepatic edge. Arrange the exam sequence to minimizes position changes. Speak loudly and slowly when telling the client how to assist.

Arrange the exam sequence to minimizes position changes. Adaptations of the physical examination sequence that limits the amount of position changes (C) during the exam are often useful for an older adult who may have age-related problems, such as decreased mobility, limited energy, or perceptual changes. (A and B) are unnecessary. (D) and is not always indicated, and may be interpreted as an example of assumed ageism. Category: Medical-Surgical

. A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? Inform the client how to protect sexual and needle-sharing partners. Teach the client about the medications that are available for treatment. Identify the need to test others who have had risky contact with the client. Discuss retesting to verify the results, which will ensure continuing contact.

Discuss retesting to verify the results, which will ensure continuing contact. Encouraging retesting (D) supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about (A, B, and C), retesting encourages the client to maintain medical follow-up and management.

While the nurse obtains a male client's history, review of systems, and physical examination, the client tells the nurse that his breast drains fluid secretions from the nipple. The nurse should seek further evaluation of which endocrine gland function? Posterior pituitary and testes. Adrenal medulla and adrenal cortex. Hypothalamus and anterior pituitary. Parathyroid and islets of Langerhans.

Hypothalamus and anterior pituitary Breast fluid and milk production are induced by the presence of prolactin secreted from the anterior pituitary gland, which is regulated by the hypothalamus' secretion of prolactin-inhibiting hormone in both men and women. Further evaluation of the hypothalamus and the anterior pituitary gland (C) should provide additional information about the secretions or lactation. Evaluation of (A, B, or D) do not support a physiologic mechanism or pathology related to mammary discharge.

The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? Method of insertion. Location of the tubes. Diameter of the tubes. Procedure for feedings.

Method of insertion. The best explanation of how a PEG tube differs from a GT is by the method of insertion (A). GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a stab wound in the abdominal wall. (B, C, and D) identify commonalities.

A nurse is preparing a teaching plan for a client who is post-menopausal. Which measure is most important for the nurse to include to prevent osteoporosis? Take a multivitamin daily. Use only low fat milk products. Perform weight resistance exercises. Bicycle for at least 3 miles every day.

Perform weight resistance exercises. Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises (C) is most important in the prevention of osteoporosis in post-menopausal women. Although (A, B, and D) provide common health maintenance behaviors, weight bearing exercise provides the best preventive measure in preventing calcium mobilization out of the bone.

The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately? Terrible nightmares. Increased nocturia. Severe muscle pain. Visual disturbances.

Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching (C). (A) is a side effect, but not life threatening. (B) is not related to statin therapy. Blurred vision (D) is a transient side effect that does not need immediate medical treatment.

A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? Notify the healthcare provider. Stop the irrigation flow. Document the finding and continue to observe. Irrigate the catheter with a large piston syringe.

Stop the irrigation flow. The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped (B) to prevent severe bladder distention. The next action is to check the external system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 ml of normal saline using a large piston syringe (D). If the obstruction is not resolved, then the healthcare provider (A) should be implemented. Category: Medical-Surgical

The nurse is caring for a client with a nursing diagnosis of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? Limit visitors to immediate family to decrease exposure to infection. Maintain "clean" technique in the change of wound dressing and IV site. Assess and document skin condition around the incision and IV site at each shift. Require the use of a face mask by staff when providing care requiring close contact.

Assess and document skin condition around the incision and IV site at each shift. Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented (C) during each shift. (A and D) are not indicated for care of this client. Sterile technique is used in the dressing change or IV site change, not (B). Category: Medical-Surgical

A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? Well, I don't have to worry about getting pregnant anymore. I can't wait to go on the cruise that I have planned for this summer. I know I will miss having sexual intercourse with my husband. I have asked my daughter to stay with me next week after I am discharged.

I know I will miss having sexual intercourse with my husband. Further teaching is needed in response to the client's misunderstanding of sexuality after a hysterectomy that is reflected in statement (C). The client's knowledge about reproduction (A), a positive outlook with plans for the future (B), and her anticipated need for assistance and support during recovery (D) indicate she understands the present status of her recovery.

What instrument should the nurse use to determine the presence of deep tendon reflexes? Goniometer. Wood's lamp. Reflex hammer. Transilluminator

Reflex hammer. Deep tendon reflexes are assessed using a reflex hammer (C). (A) is used to assess the degree of joint flexion and extension. (B) determines the presence of fungi. (D) is a light source that helps detect the presence of fluid in the sinus cavities. Category: Medical-Surgical

A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure.

Obtain consent for the procedure. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the Correct selections are (A, C, D, and E). The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent to the procedure (A), a clear-liquid diet for 24 to 48 hours prior to the procedure (E), administration of an enema (D), and fasting (C) on the morning of the procedure. Preoperative sedation is not the norm for this procedure (B), although some healthcare providers administer a mild tranquilizer.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? Muscle weakness. Urinary frequency. Abnormal involuntary movements. A decline in cognitive function

A) Muscle weakness. Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and are manifested by muscle weakness (A) and wasting. ALS does not manifest (B and C). In ALS, the client remains cognitively intact, not (D), while the physical status deteriorates.

The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the nurse to respond to first? Potassium 6.0 mEq. Daily urine output of 400 ml. Peripheral neuropathy. Uremic fetor.

A) Potassium 6.0 mEq. Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular destruction. In CRF, an increase in serum nitrogenous waste products, electrolyte imbalances, and demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath related to the accumulation of blood urea nitrogen and is a common complication of CRF, but not as significant as hyperkalemia.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? Prevention of deformities. Avoidance of joint trauma. Relief of joint inflammation. Improvement in joint strength.

A) Prevention of deformities. Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A Report the findings to the surgeon. B Irrigate the indwelling urinary catheter. C Apply manual pressure to the bladder. D Increase the IV flow rate for 15 minutes.

A) Report the findings to the surgeon. An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare provider.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? She sustained an insect bite to her left arm yesterday. She has lost twenty pounds since the surgery. Her healthcare provider now prescribes a calcium channel blocker for hypertension. Her hobby is playing classical music on the piano.

A) She sustained an insect bite to her left arm yesterday. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not.

A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration.

Bluish periumbilical skin discoloration. Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration (D) and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury. (A, B, and C) indicate inflammation of the appendix or gallbladder but do not represent an acute finding as a result of blunt abdominal trauma.

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? A 35-year-old multipara who never breastfed. A 50-year-old whose mother had unilateral breast cancer. A 55-year-old whose mother-in-law had bilateral breast cancer. A 20-year-old whose menarche occurred at age 9

B) A 50-year-old whose mother had unilateral breast cancer. The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause. Although all of the women described have one of the risk factors for developing breast cancer, (B) has the greater risk over (A, C, and D).

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? Give 20 mEq of potassium chloride. Initiate continuous cardiac monitoring. Arrange a consultation with the dietician. Teach about the side effects of diuretics.

B) Initiate continuous cardiac monitoring. Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring (B) to identify ventricular ectopy or other life-threatening dysrhythmias. Potassium chloride (A) should be given after cardiac monitoring is initiated so that the effects of potassium replacement on the cardiac rhythm can be monitored. (C and D) should be implemented when the client is stable.

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? Dyspnea. Nocturia. Confusion. Stomatitis.

B) Nocturia As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure.

The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? A Impaired physical mobility related to right-sided hemiplegia. B Risk for injury related to denial of deficits and impulsiveness. C Impaired verbal communication related to speech-language deficits. D Ineffective coping related to depression and distress about disability.

B) Risk for injury related to denial of deficits and impulsiveness. With right-brain damage, a client experience difficulty in judgment and spatial perception and is more likely to be impulsive and move quickly, which placing the client at risk for falls (B). Although clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical impairments on the contralateral side of the body, not the same side (A). The client with a left-brain injury may manifest right-sided hemiplegia with speech or language deficits (C). A client with left-brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D).

A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? The vaccine is given annually before the flu season to those over 50 years of age. The immunization is administered once to older adults or persons with a history of chronic illness. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years.

B) The immunization is administered once to older adults or persons with a history of chronic illness. It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re-vaccination is sometimes required.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? Increase the amount of calcium intake in the diet. Apply alternating heat and cold therapies. Initiate a weight-reduction diet to achieve a healthy body weight. Use a walker for ambulation to lessen weight-bearing on the hips.

C) Initiate a weight-reduction diet to achieve a healthy body weight. Achieving a healthy weight (C) is critical to protect the joints of clients with OA. Increasing the amount of calcium in the client's diet (A) will not protect hip joints from the effects of OA. Thermal therapies may lessen pain and stiffness from OA but are not protective of the joints (B). Assistive devices such as a walker may be beneficial to help avoid falls and assist in ambulation but are not protective against OA's effects (D).

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? Have you ever experienced any paralysis of your arms or legs? Have you ever sustained a severe head injury? Have you ever been 'frozen' in one spot, unable to move? Do you have headaches, especially ones with throbbing pain?

Have you ever been 'frozen' in one spot, unable to move? Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not cause (A). Parkinson's disease is not usually associated with (B), nor does it typically cause (D)

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? Helps to minimize pain and anxiety. Maintains correct spinal alignment to protect the surgical area. Prevents dizziness while stabilizing the spine. Allows the nurse to move the client freely without assistance.

Maintains correct spinal alignment to protect the surgical area Log-rolling technique maintains the spine in a straight superior-inferior plane that aligns the spine without movement while protecting the surgical area (B), which is especially important when the procedure involves bone grafts that may several weeks for the bone to fuse. (A) is best managed with client teaching, preparation before procedures, relaxation techniques, and pain management, not log-rolling. (C and D) are not accurate.