Medsurg

The nurse provides information about foods high in iron to a patient who has iron deficiency. The nurse recognizes that the teaching has been effective when the patient chooses which food item as the best source of iron? A. Two eggs B. Two slices of whole wheat bread C. One cup of cooked soybeans D. One cup of peanuts

C. One cup of cooked soybeans

Which of these 4 patients is most likely to need teaching about intrathecal chemotherapy? A. Acute lymphocytic leukemia (ALL) B. Acute myeloid leukemia (AML) C. Chronic lymphocytic leukemia (CLL) D. Chronic myeloid leukemia (CML)

A. Acute lymphocytic leukemia (ALL)

Which patient would the nurse identify as the highest risk for sickle cell anemia? A. African American B. Mediterranean origin C. Ashkenazi Jew D. Scandinavian

A. African American

Which information will the nurse provide to minimize the risk for complications of pancytopenia as a result of chemotherapy? A. Avoid activities that risk traumatic injuries and exposure to infection B. Perform frequent mouth care with a firm toothbrush C. Increase oral fluid intake to a minimum of 3L daily D. Report any unusual muscle cramps or tingling sensations in the extremities

A. Avoid activities that risk traumatic injuries and exposure to infection Rationale: Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. Aggressive oral hygiene can precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. Muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.

At which site would the nurse expect to find internal bleeding when assessing a 10-year-old boy with hemophilia who has fallen while playing on the playground? A. Joints B. Abdomen C. Cerebrum D. Epiphyses

A. Joints Rationale: Weight-baring joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from trauma. The cerebrum is protected by the skull and unlikely to be injured. Bleeding from the epiphyses is not common without other associated trauma.

Which response would a nurse give when a client who is to receive external radiation for cancer says to the nurse "My family and friends say that I will get a radiation burn?" A. "Daily application of an emollient will prevent the burn" B. "A localized skin reaction usually occurs" C. "It will be no worse than a sunburn" D. "They may be misinformed"

B. "A localized reaction usually occurs" Rationale: Localized skin reactions can occur with radiation The word "burn" may increase the clients anxiety and should be avoided. Emollients are contraindicated, they may alter the calculated x-ray route and cause injury to healthy tissue. Some skin reactions can actually be quite severe.

Which clinical finding would the nurse expect when assessing a client newly diagnosed with Myasthenia Gravis? A. Tearing B. Diplopia C. Nystagmus D. Exophthalmos

B. Diplopia Rationale: Myasthenia Gravis presents with diplopia and ptosis (double vision and droopy eyelid). Nystagmus is associated with Multiple Sclerosis. Exophthalmos is associated with hyperthyroidism.

Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints? A. Urate crystals in the synovial tissue B. Inflammation in the joint's synovial lining C. Formation of bony spurs on the joint surfaces D. Deterioration and loss of articular cartilage joints

B. Inflammation in the joints synovial lining Rationale: In RA, transformed autoantibodies attack synovium, producing inflammation. Urate crystals occur with gouty arthritis. Bony spurs are unrelated to RA. Deterioration and loss of articular cartilage in joints is osteoarthritis.

Which complication would the nurse suspect due to a patient's loss of intrinsic factor after a gastrectomy? A. Bile reflux gastritis B. Pernicious Anemia C. Dumping syndrome D. Postprandial hypoglycemia

B. Pernicious Anemia

Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? A. Interleukin 2 B. Interleukin 11 C. Beta interferon D. Alpha interferon

C. Beta interferon

Which response to a Tensilon test would confirm the diagnosis of Myasthenia Gravis? A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of only the ptosis

C. Rapid but brief symptomatic improvement Rationale: Symptom improvement will start within 30 seconds and will last no longer than 5 minutes in a positive test for Myasthenia Gravis

After the nurse has taught a patient with leukemia about the stages of chemotherapy, which patient statement indicates effective learning? A. "Consolidation therapy is the first step in my chemotherapy plan" B. "I can expect to feel a lot better once intensification therapy is started" C. "Induction therapy will help my own bone marrow fight the leukemia cells" D. "My maintenance therapy may continue for a long time after the initial chemotherapy"

D. "My maintenance therapy may continue for a long time after the initial chemotherapy"

Which complete of the complete blood count is of greatest concern to the nurse reviewing laboratory results after each round of a client's cancer chemotherapy? A. Platelets B. Hematocrit C. Red Blood Cells D. White Blood Cells

D. White blood cells Rationale: Antineoplastic drugs depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life threatening. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets.

Which question is the most useful when planning nursing care for a client who has a tonic-clonic seizure at work and is admitted to the emergency department? A. "Is your job demanding or stressful most of the time?" B. "Do you participate in any strenuous sports activities on a regular basis?" C. "Does anyone in your family have a history of CNS problems?" D. "Were you aware of anything different or unusual just before your seizure began?"

D. "Were you aware of anything different or unusual just before your seizure began?" Rationale: Identification of a sensation that occurs before each seizure (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. The other three questions may provide some useful information but they are not the most inclusive of the questions and are closed-ended questions

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. Which approach would the nurse take when interacting with this client? A. Explain why there is a need to increase activity B. Emphasize that with a prosthesis, there will be a return to the previous lifestyle C. Appear cheerful and noncritical regardless of the client's response to attempts at intevention D. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

D. Acknowledge that the clients withdrawal is an expected and necessary part of initial grieving

Which medication is most appropriate for the nurse to administer to a patient in acute sickle cell crisis who reports a pain level of 10? A. Acetaminophen oral tablets every 6 hours B. Oral morphine tablets, every 4 hours prn C. IV meperidine, every 4 hours prn D. Hydromorphone via patient-controlled analgesia (PCA)

D. Hydromorphone via patient-controlled analgesia (PCA)

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube? A. It checks for bleeding in the lung B. It monitors the function of the lung C. It drains fluid from the pleural space D. It removes air from the pleural space

D. It removes air from the pleural space Rationale: With a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps reestablish negative pressure within the pleural space; this results in lung reinflation. A closed chest drainage system may be inserted to remove blood related to a hemothorax, not to assess for bleeding. Monitoring the function of the lung is not the purpose of inserting chest tubes; the function of the lungs is monitored through the assessment of vital signs, breath sounds, arterial blood gases, and chest x-ray. Draining fluid from the pleural space is the reason for use of a closed chest drainage system the there is fluid in the pleural space.

A client who is in skin traction while awaiting surgery for repair of a fractured femur asks the nurse to release the traction because of leg pain. Which response would the nurse provide? A. "I cant do that because the weights are needed to keep the bone aligned" B. "I will remove half of the weights and notify your primary health care provider" C. "Ill get your prescribed pain medication increased to help relieve your discomfort" D. "I follow the primary health care providers directions, and that is not prescribed"

A. "I can't do that because the weights are needed to keep the bone aligned" Rationale: This answer explains why the traction cannot be released, continuous pull must be maintained. Reducing the weight requires a providers prescription. Saying "I'll get your prescribed pain medication" ignores the clients request to release the traction. Telling the client you have to follow the instructions of the HCP is a true statement but it does not provide rationale as to why the weights should not be released.

Which statement by an adolescent about sickle cell anemia would cause the nurse to conclude that the teaching has been understood? A. "Ill start to have symptoms when I drink less fluid" B. "Ill start to have symptoms when I have fewer platelets" C. "Ill start to have symptoms when I decrease the iron in my diet" D. "Ill start to have symptoms when I have fewer white blood cells"

A. "Ill start to have symptoms when I drink less fluid" Rationale: Dehydration precipitates sickling of RBC's and is a major causative factor for painful episodes associated with sickle cell anemia. Inadequate platelets, iron intake, and inadequate WBC's are all unrelated to sickle cell anemia

A client who had an above the knee amputation has a pressure dressing on the end of the residual limb. The client asks "Why do I have to have this tight dressing on my leg?" Which response would the nurse provide? A. "It decreases the swelling of the area B. "It decreases the formation of scar tissue" C. "It prevents the formation of blood clots" D. "It reduces phantom limb pain"

A. "It decreases the swelling of the area" Rationale: The pressure dressing promotes shrinkage of the residual limb to facilitate use of a prosthesis. Bandaging will not affect the formation of a scar, prevent blood clots, or reduce phantom limb pain

Which client need would the nurse prioritize while providing care for an older adult client with dementia? A. Safety B. Self-esteem C. Self-actualization D. Love and belonging

A. Safety Rationale: An older client with dementia has impaired cognition. The nurse would make arrangements such as applying bedside rails to ensure that the client's safety needs are met first. Self-esteem or self worth are not as important as safety. Self-actualization is beyond the capacity of a client with dementia. All clients need love and belonging, however safety is the first priority for this client. MASLOWS HIERARCHY OF NEEDS

The nurse is interviewing a client who was diagnosed with Systemic Lupus Erythematosus (SLE). What clinical findings to this disease would the nurse expect the client to exhibit? Select all that apply: A. Butterfly facial rash B. Firm skin fixed to tissue C. Inflammation of the joints D. Muscle mass degeneration E. Inflammation of small arteries

A. Butterfly skin rash C. Inflammation of the joints Rationale: The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the cheek region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. Firm skin fixed to tissue occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. Muscle mass degeneration occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. Inflammation of small arteries occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.

Which medication is prescribed to improve the physical manifestations of Parkinson disease? A. Carbidopa-Levodopa B. Isocarboxazid C. Dopamine D. Pyridoxine (Vit B6)

A. Carbidopa-Levodopa Rationale: Levodopa crosses the blood-brain barrier and converts to dopamine Isocarboxazid is an MAOI prescribed for severe depression. Dopamine does not cross the blood brain barrier and would not be effective. Vit B6 can reverse effects of antiparkinson medication and is contraindicated

Which action would the nurse encourage a client who has multiple sclerosis in remission and is the parent of two active preschoolers to take? A. Develop a flexible schedule for completion of routine daily activities B. Plan a schedule of specific times each day for playtime with the children C. Meet with a self-help group for people with the diagnosis of MS D. Provide support to other people with MS who also have young children

A. Develop a flexible schedule for completion of routine daily activities Rationale: The client must be flexible and adjust activities to provide for rest when necessary; activity should cease before the point of fatigue. Although quality time with children is important, it must be done on a flexible schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis who also have young children cannot be done if the client is in need of support or if it overtaxes physical resources. Meeting with a self-help group for people with the diagnosis of multiple sclerosis may not be a need at this time; prevention of fatigue always is important.

Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply: A. Encouraging regular dental checkups B. Facilitating smoking cessation programs C. Administering influenza vaccines to older adults D. Teaching the procedure for breast self-examination E. Referring clients with a chronic illness to a support group

A. Encouraging regular dental checkups D. Teaching the procedure for breast-self examination Rationale: Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply: A. Ensure the chest tube dressing is tight and intact B. Palpate the skin to detect subcutaneous emphysema C. Place the chest tube drainage system below the chest D. Quickly attempt to reinsert the chest tube if it falls outE. Strip the chest tube with long strokes to promote drainage

A. Ensure the chest tube dressing is tight and intact B. Palpate the skin to detect subcutaneous emphysema C. Place the chest tube drainage system below the chest Rationale: Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgment and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the HCP. The chest tube should not be stripped because this causes negative pressure that can cause trauma to the pleura

After an amputation of a limb, a client reports extreme discomfort in the area where the limb once was. Which goal would the nurse plan to focus interventions? A. Identifying actions to decrease pain in the lost limb B. Reversing feelings of hopelessness about the future C. Promoting mobility in the residual limb D. Facilitating the grieving process for the lost limb

A. Identifying actions to decrease pain in the lost limb Rationale: Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There is no data indicating the client is hopeless or grieving. Promoting mobility in the residual limb may be effective for some people, but not effective for others. ALL possible interventions should be explored.

Which findings would support a client's diagnosis of Parkinson disease? Select all that apply: A. Nonintentional tremors B. Frequent bouts of diarrhea C. Masklike facial expression D. Hyperextension of the neck E. Rigidity to passive movement

A. Nonintentional tremors C. Masklike facial expression E. Rigidity to passive movement Rationale: Nonintentional tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

Which assessment finding would the nurse associate with anemia? A. Pallor B. Diarrhea C. Palpitations D. Exertional Dyspnea

A. Pallor

When a patient receiving a transfusion of packed red blood cells reports itching and develops hives on the chest and abdomen, which action will the nurse take first? A. Infuse normal saline B. Stop the blood transfusion C. Take the patient's BP D. Give the prescribed antihistamine

B. Stop the blood transfusion

A client is being initiated on bisphosphonates. Which advice will the nurse provide? A. "Take it on an empty stomach" B. "This medication should be taken at night before bed" C. "These medications should be taken with food or milk" D. "Lie down for a bit after taking the medication"

A. Take it on an empty stomach Rationale: Bisphosphonates should be taken on an empty stomach in the morning and the client should remain upright for 30 minutes after taking the medication

Which action by a 70-year-old female client would best limit further progression of osteoporosis? A. Taking supplemental calcium and vitamin D B. Increasing the consumption of eggs and cheese C. Taking supplemental magnesium and vitamin E D. Increasing the consumption of milk products

A. Taking supplemental calcium and vitamin D Rationale: Research demonstrates that women past menopause need at least 1500mg of calcium a day, which is nearly impossible to obtain through dietary sources. (Average daily consumption of calcium is 300 to 500 mg)Vitamin D promotes the deposition of calcium into bone. Consumption of eggs and cheese do not contain adequate calcium to meet requirements to prevent osteoporosis. Milk and milk quantities may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

Which explanation would the nurse provide to a client about transient ischemic attacks (TIA's)? A. Temporary episodes of neurological dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurological deterioration D. Exacerbations of neurological dysfunction alternating with remissions

A. Temporary episodes of neurological dysfunction Rationale: Narrowing of arteries supplying the brain causes temporary neurological defects that last for a short period. Between attacks, neurological functioning is normal.

Which outcome would be a priority for the nurse to incorporate into the plan of care for a client with a migraine? A. To decrease pain B. To decrease nausea C. To decrease vomiting D. To decrease light sensitivity

A. To decrease pain Rationale: The priority intervention is to decrease pain because a migraine is accompanied by a severe throbbing headache. Decreasing nausea, vomiting, and light sensitivity is considered after pain is managed and may not be present for every patient presenting with a migraine.

The nurse is teaching the client about dietary control of gout. Which statement made by the client indicates successful learning? A. "I will avoid eating eggs" B. "I will avoid eating shellfish" C. "I will avoid eating fried poultry" D. "I will avoid eating cottage cheese"

B. "I will avoid eating shellfish" Rationale: Patients with gout should follow a strict low-purine diet and avoid foods such as organ meats, shellfish, and oily fish (ex. sardines) Eggs, fried poultry, and cottage cheese are low in purine

When reinforcing preoperative instructions for a client who experienced a recent hip replacement surgery, which statement indicates client understanding of instructions? Select all that apply: A. "I will sit on chairs without arms" B. "I will use an elevated toilet seat" C. "I may cross my legs at the knees or ankles" D. "I will use a firm pillow between my legs for the first 6 weeks" E. "I will keep my hips in a neutral, straight position when sitting"

B. "I will use an elevated toilet seat" D. "I will use a firm pillow between my legs for the first 6 weeks" E. "I will keep my legs in a straight, neutral position when sitting" Rationale: After hip replacement surgery, the client should not sit on chairs without arms because the client needs aid to rise to a standing position. The client should not cross legs at the ankles and knees because this may lead to severe pain or cause dislocation.

Which action would the nurse anticipate when admitting a client having a sickle cell crisis to the nursing unit? Select all that apply: A. Place on strict isolation B. Administer hydroxyurea C. Administer aspirin 325mg daily D. Apply oxygen via nasal cannula E. Administer intravenous hydration F. Avoid opiate-type analgesics

B. Administer hydroxyurea D. Apply oxygen via nasal cannula E. Administer intravenous hydration Rationale: Hydroxyurea can reduce the number of sickling and pain episodes by stimulating fetal hemoglobin production. Providing oxygen decreases RBC sickling and improves tissue oxygenation. IV hydration will decrease clumping of sickled cells and decrease blood flow obstruction. Isolation is not needed, aspirin is not helpful because the blood flow is obstructed by sickled cells, not clotting. Opiate analgesics are frequently needed for pain management because tissue ischemia caused by obstructed blood flow by sickled cells is very painful.

Which nursing intervention is correct for a client in skeletal traction? A. Add and remove weights as the client desires B. Assess the pin sites at least every shift and as needed C. Ensure that the knots in the rope are tied to the pulley D. Perform range of motion to joints proximal and distal to the fracture at least once a day

B. Assess the pin sites at least every shift and as needed Rationale: The needed weight for a client in skeletal traction is prescribed by the HCP, not as desired by the client. The nurse would also ensure that the knots are NOT tied to the pulley and move freely. ROM is indicated for all joints EXCEPT the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain

Which medication would the health care provider prescribe to treat the acute attack of gout and prevent future attacks? A. Ibuprofen B. Colchicine C. Probenecid D. Allopurinol

B. Colchicine Rationale: High-dose Colchicine decreases inflammatory response to alleviate an acute gout attack, low-dose colchicine is used prophylactically to prevent future attacks. Ibuprofen may help with acute attacks but does not prevent future attacks. Probenecid is useful for prophylaxis but does not treat acute attacks. Allopurinol is useful for prophylaxis, but does not possess anti-inflammatory properties to treat an acute attack

Which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm? A. Warm skin at the site of injury B. Escalating pain in the fingers C. Rapid capillary refill in affected hand D. Bounding radial pulse in the injured arm

B. Escalating pain in the fingers Rationale: Elevated tissue pressure restricts blood flow causing increasing ischemia and pain, it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of decreased circulation. Sluggish capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding.

Which finding would the nurse expect to identify in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis? A. Ulnar drift B. Heberden nodes C. Swan-neck deformity D. Boutonniere deformity

B. Heberden nodes Rationale: Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonniere deformity occur with rheumatoid arthritis.

Which cerebrospinal fluid (CSF) laboratory finding indicates presence of bacterial meningitis? A. Decreased cell count B. Increased protein level C. Increased glucose level D. Low spinal fluid pressure

B. Increased protein level Rationale: the CSF in a patient with bacterial meningitis will have increased protein (due to presence of bacteria), increased WBC (due to infection), and decreased glucose (due to the bacteria eating the glucose)

Which action would the nurse take first when caring for a client who is admitted to the emergency department after experiencing a seizure? A. Ask the emergency provider for a prophylactic anticonvulsant B. Obtain a history of seizure type and incidence C. Ask the client to remove any dentures and eyeglasses D. Observe the client for increased restlessness and agitation

B. Obtain a history of seizure type and incidence Rationale: Data collection is an essential first step for a client with a seizure disorder; it should always include a history of the seizures (e.g., type and incidence). Because different seizure medicines are used to control different seizure types, it is important to determine the type before treating. Although dentures and eyeglasses may be removed during a seizure, the client's normal routines should be respected. Increased restlessness may be evidence of the prodromal phase of a seizure in some individuals, but signs and symptoms vary so widely that the client's history should be obtained.

Which action would the nurse take in caring for a client after surgical placement of an external fixator on the clients leg? A. Cleanse the pin sites with alcohol several times a day B. Perform a neurovascular assessment of the lower extremities C. Ambulate the client with partial weight bearing on the affected leg D. Maintain placement of an abduction pillow between the clients legs

B. Perform a neurovascular assessment of the lower extremities Rationale: NVA identifies signs and symptoms of compartment syndrome, the nurse should monitor for the 6 P's: pain, pallor, paresthesia. pressure, pulselessness, and paralysis. Maintaining abduction of the leg is not necessary with an external fixation of the tibia. The client should initially use a wheelchair or walk without bearing weight on the affected extremity. There is no established standard of care with pin care, some providers believe pin care is contraindicated because it disrupts the skins natural barrier to infection.

Which diagnostic test result indicates a diagnosis of Hodgkin Lymphoma? A. Lymphoblasts in the CSF B. Reed Sternberg cells in the lymph node C. Hypercellular bone marrow with myeloblasts D. Philadelphia chromosome in the bone marrow cells

B. Reed sternberg cells in the lymph node

While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above heart level. Which statement describes the rationale behind this nursing action? A. To promote bone density B. To prevent further edema C. To reduce pain perception D. To increase muscle strength

B. To prevent further edema Rationale: A client with a second-degree sprain will likely have swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilize excess fluid from the area and prevents further edema. Strengthening exercises help build bone density and muscle strength and will reduce the risk of sprains and strains. Cryotherapy and adequate rest will help reduce perception of pain impulses.

Which instructions would the nurse include when discharging a patient with thrombocytopenia? Select all that apply: A. Use a high-quality disposable razor for shaving B. Take aspirin or ibuprofen to treat minor discomforts C. Avoid blowing your nose forcefully. Instead, gently pat it with a tissue D. Use a small volume enema or rectal suppository to treat constipation E. Notify your health care provider if you have black, tarry bowel movements F. Notify your health care provider if you have difficulty speaking or sudden weakness in the arm or leg

C. "Avoid blowing your nose forcefully. Instead, gently pat it with a tissue." E. "Notify your health care provider if you have black, tarry bowel movements." F. "Notify your health care provider if you have difficulty speaking or sudden weakness in the arm or leg." Rationale: Self-care measures to reduce the risk of bleeding include avoiding blowing the nose forcefully. It is also important to notify the health care provider of any black, tarry stools, as this is a sign of upper gastrointestinal bleeding. The patient should notify the health care provider of difficulty speaking or sudden weakness in the extremities. This can indicate that the patient may be experiencing an intracerebral hemorrhage. Patients with thrombocytopenia should not use a razor blade to shave; an electric razor is preferred due to bleeding potential. Patients with thrombocytopenia should not take aspirin or ibuprofen, as these drugs increase the risk of bleeding. Constipation should be avoided by increasing fluid intake and using stool softeners. Enemas and rectal suppositories should be avoided because their use may result in bleeding.

Which explanation will the nurse provide to a client with cancer who develops pancytopenia during the course of chemotherapy and asks the nurse why this has occurred? A. "The medications used for chemotherapy interacted with other medications you are taking" B. "Lymph node activity is depressed by the radiation therapy used before chemotherapy" C. "Noncancerous cells are also susceptible to the effects of chemotherapeutic medications" D. "Dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration"

C. "Noncancerous cells are also susceptible to the effects of chemotherapeutic medications" Rationale: Chemotherapy destroys erythrocytes, white blood cells, and platelets indiscriminately along with the neoplastic cells because these are all rapidly dividing cells that are vulnerable to the effects of chemotherapy. Stating that steroid hormones have a depressant effect on the spleen and bone marrow is not a true description of the side effects of steroids. Depressed lymph node activity as a result of radiation therapy used before chemotherapy is not the cause for fewer erythrocytes white blood cells, and platelets. Although it is true that dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration, this does not explain pancytopenia.

Which initial response by the nurse is best when a client with lymphoma expresses discouragement during treatment because of chemotherapy side effects? A. Ask whether the client has considered using antidepressants B. Remind the client that positive thoughts can be therapeutic C. Acknowledge that the adverse effects of treatment are difficult to endure D. Offer information about the effectiveness of chemotherapy for the lymphoma

C. Acknowledge that the adverse effects of treatment are difficult to endure Rationale: This recognizes the clients concern and opens the door to further sharing of concerns by the client

When a client develops bacterial meningitis, what action is the nurse's priority? A. Monitoring for signs of intracranial pressure B. Adding pads to the side of the bed C. Administering prescribed antibiotics D. Administering glucocorticoids

C. Administering prescribed antibiotics Rationale: For bacterial meningitis, the client's greatest need is a regimen of antibiotics. BM causes increased ICP and it is important for the nurse to monitor for manifestations of increased ICP, however it is not the priority because monitoring alone does not affect outcome. Padded side rails are important because of the risk of seizures, but it does not have priority over administering antibiotics. Glucocorticoid admin is important to improve outcomes but antibiotics are even more important because without them the infection will continue and can be life threatening.

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A. Asks to have the food moved to the left side of the tray B. Drops the coffee cup when trying to use the right hand C. Ignores the food on the left side of the tray when eating D. Reports not being able to use the right arm to help eat meals

C. Ignores the food on the left side of the tray when eating Rationale: Clients with hemianopsia affecting the left field of vision cannot see whatever is in the left field of vision. Asking to have food moved to the left side of the tray may occur if the client has right hemianopsia and wishes to see better when eating. Dropping the coffee cup when trying to use the right hand may occur with right hemiparesis, not with hemianopsia. Reporting about not being able to use the right arm to help eat indicates hemiplegia, not hemianopsia

Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? A. Moving the client's bedside table closer to the bed B. Encouraging the client to take an available sedative C. Instructing the client to call the nurse before going to the bathroom D. Assisting the client to telephone home to say goodnight to the spouse

C. Instructing the client to call the nurse before going to the bathroom Rationale: Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to go to the bathroom unassisted. Moving the bedside table closer to the bed is helpful in preventing falls, but it is not the primary intervention to prevent falls. Sedatives contribute to fall risk and talking to the spouse may calm the patient and contribute to sleep, but does not reduce incidence of falls.

Which information would the nurse include in the teaching plan for the client who is prescribed sumatriptan for migraine headaches? A. It should be administered when headache is at its peak B. It should be administered by deep intramuscular injection C. It is contraindicated in people with coronary artery disease D. Injectable sumatriptan may be administered every 6 hours as needed

C. It is contraindicated in people with coronary artery disease Rationale: In addition to promoting therapeutic cerebral vasoconstriction, sumatriptan promotes undesirable coronary artery vasoconstriction. Coronary vasoconstriction may cause harm to the client with CAD. Sumatriptan should be administered when the first symptoms of a migraine appear. It may be given orally, subcut, or as a nasal spray.

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA) with residual hemiparesis and hemianopsia? A. Necessity for bed rest at home B. Use of oxygen therapy at home C. Significance of a safe environment D. Need for decreased protein in the diet

C. Significance of a safe environment Rationale: Safety becomes a priority when the client has hemiparesis (paralysis on one side) and hemianopsia (abnormal visual field). Although a balance between activity and rest is important, the client does not have to maintain bed rest. Oxygen generally is not necessary. All the basic nutrients should be included in the diet; there is no reason to reduce protein intake.

Which assessment is the nurse's priority before beginning an infusion of tissue plasminogen activator (tPA) to a client in the emergency department? A. Vital signs B. ECG monitoring C. Signs of bleeding D. Level of chest pain

C. Signs of bleeding Rationale: Assessment for bleeding is a priority because it is a contraindication for administration of thrombolytic agents and can lead to life-threatening hemorrhage. All of the other options are important but are not life-threatening contraindications to tPA administration

Which property would the nurse understand that the medication is being used primarily for when aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis? A. analgesic B. antipyretic C. anti-inflammatory D. anti-platelet

C. anti-inflammatory Rationale: The anti-inflammatory action of aspirin reduces joint inflammation. It can relieve pain and prevent abnormal clotting, but these are not the primary reasons it would be prescribed. Aspirin also reduces fever, but this is not the rationale for clients with RA.

Which clinical finding is consistent with an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D. Lowered level of consciousness Rationale: Altered consciousness is the first sign of increased ICP. Other signs may be slow pulse, widened pulse pressure, and irregular respirations

Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? A. Go for additional help B. Establish a patent airway C. Restrain the client to prevent injury D. Protect the clients head from injury

D. Protect the clients head from injury Rationale: Protecting the head is the only appropriate nursing action during a seizure. The client should never be left unattended or restrained. Establishing a patent airway is done AFTER the seizure, you should NEVER insert anything into the patients mouth during a seizure.

Which area of assessment is included in Glasgow Coma Scale? A. Breathing patterns B. Deep tendon reflexes C. Eye accommodation to light D. Response to verbal commands

D. Response to verbal commands Rationale: The Glasgow Coma Scale determines LOC using 3 areas of assessment: 1. Motor response to verbal commands 2. Eye opening in response to speech 3. Verbal response to speech

The nurse provides self-care instructions to a client who is receiving external radiation therapy for bone metastases. Which client activity demonstrates a need for further teaching? A. Protecting the skin from direct sunlight B. Wearing loose-fitting cotton clothing over the area C. Drying the area with a patting motion using a soft towel D. Rubbing on talcum powder after washing the area

D. Rubbing on talcum powder after washing the area Rationale: No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.