Medsurg EAQ's

The nurse is caring for a client after transsphenoidal hypophysectomy and observes clear drainage from the nares. Which statement is accurate in explaining the cause of this drainage?

Cerebral spinal fluid could be leaking from an opening to the brain. Rationale: Transsphenoidal hypophysectomy is removal of the pituitary gland. This procedure is close to the brain. Clear drainage from the nares could indicate a cerebral spinal fluid (CSF) leak. The nurse should contact the primary health care provider and send the drainage to the laboratory for glucose evaluation. If the glucose level is greater than 30 mg/dL, this would indicate a CSF leak. This is not a normal occurrence postoperatively for this procedure. Clear drainage would not indicate an infection.

Which information would the nurse plan to teach a client with a supratentorial brain tumor who is scheduled for external radiation therapy?

Expect to feel very tired. Rationale: External radiation causes fatigue, regardless of the site; myelosuppression and its resultant anemia occur more frequently when radiation therapy involves the skull, pelvic region, sacrum, ribs, shoulder region, sternum, and thoracic and lumbar vertebrae. A low-residue diet is not necessary because the gastrointestinal tract is not affected. The dose is individualized and depends on safety, malignant cell type, location of malignancy, and cellular sensitivity. Loss of memory does not occur with this treatment. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing

Which intervention would the nurse implement for a client with Parkinsonism who takes an anticholinergic medication for morning stiffness and tremors in the right arm who reports some numbness in the left hand during a visit to the clinic?

Make immediate arrangements for further medical evaluation by the client's primary health care provider. Numbness, a sensory deficit, is inconsistent with Parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending cerebrovascular accident (CVA). Parkinsonism does not have this symptom. Increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary health care provider as soon as possible can cause a delay in the client receiving immediate medical attention.

Which nursing action would be in the plan of care of a client who had a cerebrovascular accident and now leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field?

Teaching the client to use head movement to scan the left field vision. rationale: The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. The client should be approached from the right side because the left visual field is impaired. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. Although it may help temporarily to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

Which route of administration will be used to deliver conscious sedation to a client during a cardiac catheterization?

Through an intravenous catheter Rationale Conscious sedation is administered by direct intravenous (IV) injection or IV push to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. A nerve block, a type of regional anesthesia, is achieved by injection of the anesthetic agent into or around the nerves supplying the area; it interrupts sensory, motor, and sympathetic transmission.

Which intervention would the nurse provide an infant exhibiting signs of increased intracranial pressure (ICP)?

Elevating the infants head higher than the hips

Which information would the nurse include in a response when the family members of a client with the diagnosis of cerebrovascular accident express concern that the client often becomes uncontrollably tearful during their visits?

Emotional lability is often associated with brain trauma

Which position would the nurse place a client in during the immediate period after injury to the frontal lobe of the brain?

Low- Fowler

which statement about administration IV potassium would a nurse make to a client with a diagnosis of hypokalemia? Oliguria is an indication for withholding IV potassium.

Oliguria is an indication for withholding IV potassium.

Where would the nurse find the area of involvement associated with parietal swelling?

On top of the skull

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant with hydrocephalus?

Palpating the anterior fontanel

Which assessment finding alerts the nurse to suspect increasing intracranial pressure in an infant?

Projectile vomiting

Which factor is a likely cause of hyponatremia?

Select all that apply. One, some, or all responses may be correct. Diabetes insipidus Profuse diaphoresis Excess sodium intake Removal of the parathyroid glands Rapid intravenous (IV) infusion of 5% dextrose in water (D W)

Which statement applies to a client who is on long-term corticosteroid therapy after an adrenalectomy and admitted to the surgical intensive care unit after being involved in a motor vehicle crash?

Steroid therapy will need to be increased to avert a life-threatening crisis. Rationale Clients with adrenocorticoid insufficiency who are receiving steroid therapy require increased amounts of medication during periods of stress because they are unable to produce the excess needed by the body. With severe stress, a failure to ensure adequate corticosteroid levels can be life-threatening. Increased stress requires an increase, not a decrease, in glucocorticoids. Although osteoporosis may have contributed to fractures secondary to trauma, this does not present a current risk. Cushing syndrome is a problem with excess corticosteroid therapy, but after an adrenalectomy, the corticosteroid is given in amounts sufficient to replace what the body cannot produce.

Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus?

Supine on the unaffected side

Which behavior by a client who had a cerebrovascular accident (CVA) beginning to eat lunch indicates the client may be experiencing left hemianopsia?

The client ignores the food on the left side of the tray when eating.

Which instruction will the nurse include when educating the client about enalapril maleate?

When standing up, change position slowly. Rationale Enalapril is an angiotensin-converting enzyme inhibitor and can cause postural hypotension. For safety purposes, the client should be instructed, when standing, to change positions slowly to avoid dizziness or fainting. It is not necessary to take the medication with orange juice. Checking pulse rate is not indicated before administration; checking blood pressure is indicated. Although electrolytes often are checked for clients with hypertension who are receiving medication therapy, weekly basic metabolic panels are not required while taking this medication.

which imaging technique is specific for alzheimer disease

magnetic resonance spectroscopy. (MRS)

A 6-year-old child is prescribed carbamazepine 15 mg/kg/day divided equally into two doses for clonic seizures. The child weighs 44 lb (20 kg). The medication available is carbamazepine suspension 100 mg/5 mL. How many milliliters would the nurse administer in one dose? Record your answer using one decimal place.

7.5ml

Which information will the nurse include when teaching a client with hypertension about metoprolol?

Do not abruptly discontinue the medication. RATIONALE: Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. The pulse rate can go lower than 70 beats per minute as long as the client is asymptomatic. Clients should never increase medications without medical direction.

Which information is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonic-clonic seizure and being diagnosed with a seizure disorder?

Explain stratergies a client may use to prevent physical trauma from occuring

A child with a viral infection was treated with aspirin and developed Reye syndrome. Which nursing intervention would be beneficial for this child?

Initiate hyperventilation

Which adverse effect will the nurse monitor for when caring for a client with multiple myeloma who is receiving the alkylating agent melphalan and returns to the oncology clinic for a follow-up visit?

Leukopenia Rationale: Melphalan depresses the bone marrow, causing a reduction in white blood cells (leukopenia), red blood cells (anemia), and thrombocytes (thrombocytopenia); leukopenia increases the risk of infection. Hirsutism occurs with the administration of androgens to women. Diarrhea, not constipation, occurs with melphalan. Photosensitivity occurs with 5-fluorouracil, floxuridine, and methotrexate, not with melphalan.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. Which action is the priority nursing intervention during the first 24 hours?

Placing the infant in a prone or side-lying position

Which intervention would the nurse include in the plan of care for a client with moderate Alzheimer disease?

Provide consistency

Which instructions will the nurse give to a client with a seizure disorder who is prescribed phenytoin?

Provide meticulous oral hygiene. Rationale: Phenytoin can cause gingival overgrowth that increases the risk for periodontal disease. The medication should be taken with food or milk to decrease gastrointestinal side effects. The health care provider should oversee any dosage adjustment or discontinuation. Although it can affect the developing fetus, current evidence suggests that the effect of seizure activity on the developing fetus may cause even greater problems

For which reason would a lumbar puncture (LP) be performed on a client? Select all that apply. One, some, or all responses may be correct.

Reading cerebrospinal fluid pressure (CFS) Injecting contrast medium for diagnostic study

Which medication corrects for deleterious effects of anaerobic energy production when a client's cells are deprived of oxygen during a cardiac arrest?

Sodium Bicarbonate Rationale In the absence of oxygen, the body derives its energy anaerobically; this results in a buildup of lactic acid. Sodium bicarbonate, an alkaline medication, will help neutralize the acid, raising the pH. Insulin is used to treat diabetes; it lowers blood sugar by facilitating transport of glucose across cell membranes. Calcium gluconate is used to treat hypocalcemia. Although potassium is essential for cardiac function, it will not correct acidosis. With acidosis, serum hydrogen ions will exchange with intracellular potassium, leading to a temporary hyperkalemic state; therefore potassium chloride is contraindicated until acidosis is corrected.

Which description of symptoms is consistent with dementia of the Alzheimer type?

Symptoms reflect progressive disintegration.

How would the nurse reply when a client prescribed a tetracycline class medication asks why milk and antacids should be avoided before and after dosing?

This can lead to decreased absorption of the medication you need. Rationale Tetracyclines chelate with calcium, iron, and magnesium, so substances containing these minerals are avoided to optimize absorption of the antimicrobial. MIlk and antacid use with tertacylcines does not increase kidney impairment, tooth staining, or diarrhea.

Which client response is indicative of a hypoglycemic reaction? Select all that apply. One, some, or all responses may be correct.

Tremors Confusion Diaphoresis RATIONALE: Tremors are a sympathetic nervous system response that occurs because circulating glucose in the brain decreases. Confusion is typically the first sign of a hypoglycemic reaction. Diaphoresis is a cholinergic response to hypoglycemia. Hypoglycemia causes hunger, not anorexia. Because blood glucose is low in hypoglycemia, the renal threshold is not exceeded and glycosuria does not occur

Which statement would a nurse make when a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion during a seizure? Select all that apply. One, some, or all responses may be correct.

*These seizure increase the risk for injuries from a fall *These seizures are most resistant to medication therapy

A health care provider prescribes 250 mg of an antibiotic intravenous piggyback (IVPB). A vial containing 1 gram of the powdered form of the medication must be reconstituted with 2.8 mL of diluent to form a volume of 3 mL. How many mL of the solution will the nurse administer? Record your answer using one decimal place and leading zero if applicable. Do not include units in your answer. mL

0.8 ml

In which order will the nurse perform the actions associated with insulin administration?

1. Wash hands with soap and water 2. Rotate the vial of insulin between the palms of the hands 3. Wipe the top of the insulin vial with alcohol swab 4.Instill air into the vial of insulin equal to the desired dose 5. Withdraw the correct amount of insulin from the inverted vial

Which development indicates to the nurse that the dosage of thyroxine to manage hypothyroidism should be reduced?

Diaphoresis Tachycardia Nervousness RATIONALE: Diaphoresis, tachycardia, and nervousness are signs of hyperthyroidism, which indicate that too much medication is being taken. Weight gain and cold intolerance indicate that the medication has not yet been effective.

Which behavior would the nurse observe when caring for a client with major neurocognitive disorder?

Liability. Rationale: lability of mood is common with major neurocognitive disorder.

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct.

Loopside smile Unilateral Vision Incoherent Speech Unable to raise right arm Symptoms started 2 hrs ago

Which statement explains lower leg numbness in a client with leukemia who is receiving vincristine?

Peripheral neuropathies can result from vincristine chemotherapy. RATIONALE: Muscle weakness, tingling, and numbness are related to medications like vincristine; neuropathies usually are transient if the medication is stopped or reduced. Nodal enlargement produces vascular rather than neural side effects. Most chemotherapeutic regimens do affect the nervous or peripheral vascular system; neuropathies and peripheral vascular adaptations are potential side effects of chemotherapy. Tingling and numbness are characteristic of neuropathy, not vascular occlusion.

Which eye muscle is controlled by cranial nerve VI

Lateral Rectus

Which assessment finding reflects increased intracranial pressure (ICP)?

Unequal pupil size

Which cranial nerve emerges from the client's medulla?

Hypoglossal.

Which symptoms would the nurse recognize as indicative of increased intracranial pressure in a 3-year-old child? Select all that apply. One, some, or all responses may be correct. Vomiting Headache Irritability Tachypnea Hypotension

a.Vomiting b.Headache c.Irritability d.Tachypnea e.Hypotension ANSWERS: A.B.C

Which complication is a client with rheumatoid arthritis at risk for due to prolonged use of corticosteroids?

Decrease White Blood cells Rationale Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. C-reactive protein and sedimentation rate are elevated in acute inflammatory diseases; steroids help decrease them. Serum glucose levels increase with steroid use.

Which response would the nurse make to the spouse of a client who had a cerebrovascular accident and seems unable to accept the goal that the client will participate in self-care?

Ask the spouse for assistance in planning activities most helpfuls to the client.

Which action will the nurse take when a client with an intravenous (IV) infusion containing 40 mEq of potassium reports a stinging pain at the IV site? S

Assess the IV site. Verify that the potassium is adequately diluted and infusing too rapidly. Rationale It is important to first make sure that the IV catheter is patent and that there is no infiltration. The potassium dosage is large and can be very irritating to veins if it isn't sufficient diluted or if it infuses too rapidly. A 40- mEq dose should be diluted in at least 1 L of IV solution. Rstarting the IV in another vein without assessment does not address the complaint. Although imagery may help distract the client from discomfort, this response provides no information as to why the stinging sensation is occurring. Asking the provider for an analgesic doesn't address the underlying problem.

A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which part of the client's assessment?

Assessment of the clients breath

Which medication is indicated to treat bradycardia for a client whose heart rate drops to 38 beats/minute during a procedure?

Atropine sulafate RATIONALE: blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate. Digoxin slows the heart rate; hence, it would not be indicated in this situation. Lidocaine decreases myocardial sensitivity and will not increase the heart rate. Amiodarone is an antidysrhythmic medication used for ventricular tachycardia; it will not stimulate the heart rate.

Which effect of atenolol is responsible for frequent dizziness in a client with hypertension?

Blocking the adrenergic response Rationale The beta-adrenergic blocking effect of atenolol decreases the heart's rate and contractility; it may result in orthostatic hypotension and decreased cerebral perfusion, causing dizziness. Depleting acetylcholine is not an action of atenolol. Stimulating histamine release is not an action of atenolol. Decreasing adrenal release of epinephrine is not an action of atenolol.

Which response to morphine would need to be reported immediately to the health care provider?

Bradycardia Rationale Because morphine is a central nervous system depressant, it may cause bradycardia, shock, and cardiac arrest. Although nausea, headache, and drowsiness may be a response to morphine, they do not have to be reported.

Which outcome would the nurse anticipate when metoprolol is administered with digoxin to a client with hypertensive heart disease who had an acute episode of heart failure?

Bradycardia Rationale Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These medications may cause hypotension, not hypertension. These medications may depress nodal conduction; therefore junctional tachycardia would be less likely to occur

Which aspect would the nurse assess to determine whether intracranial pressure is increasing around the medulla? Select all that apply. One, some, or all responses may be correct.

Breathing & HR

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. Which advice would the nurse give the partner?

Bring the partner to the clinic for testing and a physical examination.

Which type of surgery involves opening the skull with a drill?

Burr hole

Which condition causes impaired speech coordination? Cranial nerve lesion Occipital lobe lesion Parietal cortex lesion Limbic lobe lesion

Cranial nerve lesion. esions can cause a lack of coordination in articulating speech, because the cranial nerves are responsible for speech coordination. Occipital lobe lesions may lead to loss of vision. Parietal cortex lesions can cause an inability to recognize spatial or body positioning perception. Limbic lesions could interfere with emotions, learning, and memory.

Which physiological response will occur if a client being treated for myocardial infarction experiences the intended therapeutic effect of morphine?

Decreased workload of the heart Rationale Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine; it is not the intended therapeutic effect for a client being treated for myocardial infarction. Morphine causes peripheral vasodilation but not coronary artery dilation. Decreasing metabolites within the ischemic heart muscle is not the action of morphine.

A child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes the child is displaying the oculocephalic reflex. Which conclusive response to the presence of the oculocephalic reflex in an unconscious child would the nurse have?

Unusual ****Expected**** Suppressed Hyperactive

Which factors can trigger a client's migraine attacks? Select all that apply. One, some, or all responses may be correct

*Fatigue *Sleep problems *Hormonal fluctuations. Rationale Fatigue tires the body and causes headaches. Sleep problems may increase the risk for disturbance to the brain. Hormonal fluctuations in different stages can trigger a migraine attack. Vertigo, aphasia, and tingling sensations are the symptoms of migraine headaches, not triggers.

Which blood component will the nurse check for an increase in when monitoring effectiveness of filgrastim in a client who is immunosuppressed?

white blood cells Rationale Filgrastim, a granulocyte colony-stimulating factor, increases the production of neutrophils with little effect on the production of other blood components. The production of platelets is not stimulated by filgrastim. The production of erythrocytes is not stimulated by filgrastim. Neutrophils, not lymphocytes, are the white blood cells whose production is stimulated by filgrastim.

Which purpose would potassium chloride added to the intravenous solution of a client with diabetic ketoacidosis serve?

Prevent Hypokalemia

Which purpose of metoclopramide administered intravenously 30 minutes before initiating chemotherapy for cancer of the colon would the nurse explains to a client?

To stimulate peristalsis of the Upper GI tract Rationale Prokinetic medications such as metoclopramide stimulate peristalsis in the GI tract. This enhances the emptying of stomach contents into the duodenum to decrease gastroesophageal reflux and vomiting, all of which are precipitated by chemotherapeutic agents. Metoclopramide does not stimulate the production of gastrointestinal secretions. Metoclopramide has no effect on the excretion of chemotherapeutic medications. Metoclopramide has no effect on the absorption of chemotherapeutic medications

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)?

Transient ischemic attacks (TIAs) TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a cerebrovascular accident (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.

Which action would the nurse take for a daughter who states that she gives sleeping pills to her live-in mother who has dementia to stop wandering at night?

Explore hiring a home health aid to stay with the client at night

Question 19 How will the nurse respond to a client prescribed levothyroxine for hypothyroidism when the client asks whether she can become pregnant while taking levothyroxine?

*"This medicine will not interfere with your ability to become pregnant." Hormone replacement should stabilize the metabolic rate and should not interfere with the client's becoming pregnant. If thyroid function remains controlled, there is no reason why the client should not become pregnant. Because thyroid function will be normalized, the fetus will not be negatively affected, and pregnancy risk will not be increased

Which factor is unique to vascular dementia when comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type ?

Abrupt onset of symptoms. The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Memory impairment and difficulty making decisions may or may not be a symptom of vascular dementia; it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment and difficulty with decision-making, but not abruptly. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

Which action is likely to reduce the pancreatic and gastric secretions of a client with pancreatitis?

Administering prescribed anticholinergic medicationAnticholinergic drugs block the neural impulses that stimulate pancreatic and gastric secretions; they inhibit the action of acetylcholine at postganglionic cholinergic nerve fibers. Oral fluids stimulate pancreatic secretion and are contraindicated. Morphine sulfate is an analgesic and therefore does not decrease gastric secretions; in the past morphine sulfate was contraindicated for pain control with pancreatitis because it can precipitate spasms of the smooth musculature of the pancreatic ducts and the sphincter of Oddi. However, recent research indicates that it is the drug of choice over meperidine hydrochloride because the metabolites of meperidine hydrochloride can cause central nervous system irritation and seizures. The semi-Fowler position decreases pressure against the diaphragm; it will not decrease pancreatic secretions.

Which medication indicated for treatment of ventricular dysrhythmias would a nurse recall when caring for a client whose cardiac monitor indicates multiple multifocal premature ventricular complexes (PVCs)?

Amiodarone RATIONALE: Amiodarone has an antiarrhythmic action that stabilizes cell membranes of the heart, reducing cardiac excitability; it is used for acute ventricular dysrhythmias. Epinephrine increases the contractibility of the heart; the effect is opposite of that which is needed. Methyldopa is used to treat hypertension, not PVCs. Hydrochlorothiazide is a diuretic used for hypertension, not for correcting multiple PVCs.

Which assessment finding in a child being monitored for a closed head injury would require the nurse to notify the health care provider?

Answer= vomiting

Which clinical finding indicates that toxicity has occurred in a client receiving doxorubicin infusions for treatment of acute lymphocytic leukemia?

Cardiac rhythm abnormalities Rationale Doxorubicin is cardiotoxic, which is manifested by transient electrocardiogram (ECG) abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect. Dyspnea and a metallic taste to food are not effects of doxorubicin.

Which treatment strategy would the nurse conclude is the cause of the diarrhea several days after a health care provider prescribes bed rest, loperamide, and esomeprazole for a client who just had major surgery?

Esomeprazole Rationale Esomeprazole, a proton-pump inhibitor, may cause diarrhea. Loperamide, an antidiarrheal, may cause constipation, not diarrhea. Immobility causes constipation, not diarrhea. Although diet can affect elimination, there is no information presented to support this conclusion.

Which action will the nurse take when caring for a client with chronic arterial insufficiency of the legs who refuses the prescribed dose of aspirin (ASA) and states "My legs are not painful."?

Explain the reason for the medication and encourage the client to take it RATIONALE: Aspirin is given to the client to prevent platelet aggregation and possible deep vein thrombosis. The client needs information to make an educated decision. Aspirin is not prescribed to relieve pain. The client should receive information and support before making the decision to refuse the medication. Clients should never be pressured to take medication, especially when they do not have an understanding of the risks and benefits of the medication.

Which factor would the nurse consider when planning activities for an older resident in a long-term care facility with a diagnosis of neurocognitive disorder?

Familiar activities that the resident can complete successfully

Which clinical finding supports the conclusion by a nurse that a client has had a hypoglycemic reaction to insulin? Select all that apply. One, some, or all responses may be correct.

Irritability Heart Palpitations RATIONALE: Irritability, a neuroglycopenic symptom, occurs when the glucose in the brain declines to a low level. Heart palpitations, a neurogenic symptom, occur when the sympathetic nervous system responds to a rapid decline in blood glucose. Because the blood glucose level is decreased, the renal threshold is not exceeded, and there is no glycosuria. Dry, hot skin is consistent with dehydration, which often is associated with hyperglycemic states. Fruity odor of the breath is associated with hyperglycemia; it is caused by the breakdown of fats as a result of inadequate insulin supply.

Which response will the nurse give to a client with chronic angina pectoris when asked why isosorbide dinitrate is prescribed?

It decreases cardiac oxygen demand RATIONALE: Isosorbide dinitrate dilates peripheral veins and arteries thus decreasing preload and decreasing oxygen demand. Preventing blood from clotting is the action of anticoagulants. Suppressing irritability in the ventricles is the action of antidysrhythmics. Increasing the force of contraction of the heart is the action of cardiac glycosides.

Which substance history of a severe allergic reaction results in avoidance of the cephalosporins such as cefazolin, cefditoren, cefotetan, and ceftriaxone? Select all that apply. One, some, or all responses may be correct.

Milk ,Aspirin ,Calcium ,Penicillin ,Strawberries Correct: *Milk *Aspirin *Calcium *Penicillin Rationale: PENICILLIN:Use of cephalosporins like cefazolin should be avoided in the client with a history of severe allergic reaction to penicillin because of the potential of cross-sensitivity. MILK: The cephalosporin cefditoren should not be administered to the client with a milk allergy because it contains the milk protein caseinate. ASPIRIN: Bleeding can be magnified with the use of aspirin and the use of the cephalosporins cefotetan or ceftriaxone. CALCIUM:The cephalosporin ceftriaxone and calcium should not be administered together because they cause the formation of precipitates. Strawberry allergies do not prohibit the use of these medications.

Which instruction would the nurse include when teaching a female client with a new infant who is prescribed amoxicillin for a urinary tract infection?

Report signs of allergic reaction such as skin rash or itching. Rationale Penicillin class medications have a high incidence of allergic reaction, so the client should monitor for allergy and report symptoms of an allergic reaction. Amoxicillin may be taken with food. The entire course of treatment should be completed, not stopped when symptoms are absent. It is safe to breast-feed with amoxicillin.

Which is the priority nursing intervention for a client with severe preeclampsia?

Promoting a calm environment without noxious stimuli. Bed rest, a quiet room, and minimal stimulation are implemented to reduce the risk of seizures. The client will need frequent monitoring and should not be isolated. Maintaining a supine position may cause temporary supine hypotension and resultant fetal bradycardia; it also may result in aspiration if a seizure occurs. Fluids may be restricted in the pre-eclamptic client.

Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis?

Receives long-term steroid therapy RATIONALE: Receives long-term steroid therapyIncreased levels of steroids will accelerate bone demineralization. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization. Estrogen promotes deposition of calcium into bone which may prevent, not cause, osteoporosis.

Which response would the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

Resolution of heart failure Rationale Digoxin improves cardiac output to improve heart failure. Digoxin is not an antianginal medication; if it decreases angina as a result of controlling heart failure, it is a secondary effect. Digoxin may be given to control a rapid ventricular response to atrial fibrillation, but it does not convert the rhythm. Digoxin has a negligible effect on blood pressure; therefore it is not an antihypertensive medication.

Which response is a therapeutic effect of hydrocortisone prescribed for a client with Addison's disease?

Supports a better response to stress Rationale Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrates, fats, and proteins, causing elevation of the blood glucose level. Thus it enables the body to adapt to stress. It may promote fluid retention that results in hypertension and edema. Shortness of breath (dyspnea) is caused by hypovolemia and decreased oxygen supply; neither is affected by hydrocortisone. It may cause potassium depletion.

When providing care for a client with a traumatic brain injury and increased intracranial pressure, which health care provider prescription would the nurse question?

Teach isometric exercises

Which clinical finding would the nurse recognize as a sign that an infant's intracranial pressure has increased?

Tension of the anterior fontanel. Rationale: The anterior fontanel will be widened and tense because of the increased volume of cerebrospinal fluid. The pulse rate will be decreased with increased intracranial pressure. The reflexes will be hyperactive with increased intracranial pressure. The blood pressure will be higher with increased intracranial pressure.

Which explanation would the nurse provide about the client's behavior when family members of a client who had a cerebrovascular accident (CVA) ask why the client cries easily and without provocation?

Has little control over this bahavior. Rationale: Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system most responsible for emotions). Crying easily is not attentiongetting behavior; lability of mood is a physiological response to the CVA. There are inadequate data to come to the conclusion that the client feels guilt. Lability of mood is a physiological response to the CVA. The client may have remote memory, but there is no selective process of what events are remembered.

A client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output?

Inadequate antidiuretic hormone (ADH)

Which insulin will the nurse prepare for the emergency treatment of ketoacidosis?

Insulin aspart (NovoLog) Rationale Insulin aspart is a rapid-acting insulin (within 10-20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic ketoacidosis, the individual needs rapid-acting insulin.

A client who is receiving medication for an eye disorder reports bleeding in the eye. Which drug will the nurse most likely observe written in the medication administration record?

Ketorolac Rationale Ketorolac is a nonsteroidal anti-inflammatory medication that may disrupt platelet aggregation and can lead to bleeding in the eyes. Trifluridine is the topical antiviral agent that may cause sensitive reactions such as itching. Natamycin is an antifungal agent that may cause itching lids and burning eyes due to sensitivity. Ciprofloxacin is an anti-infective agent that may cause blindness if not taken in prescribed amounts.

For which condition is an oral hypoglycemic agent indicated?

Reduced insulin production RATIONALE: Oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type 2 diabetes. Rapid-acting regular insulin is needed to reverse ketoacidosis. Obesity does not offer enough information to determine the status of beta cell function. Oral hypoglycemics are not routinely indicated for the treatment of pancreatitis.

Which mechanism of sodium nitroprusside would a nurse recall is responsible for decreasing blood pressure?

Relaxing arterial smooth muscles Rationale This medication decreases blood pressure by relaxing venous and arteriolar smooth muscles and is used for immediate reduction of blood pressure. This medication may increase the heart rate as a response to vasodilation. It decreases cardiac workload by decreasing preload and afterload. It decreases peripheral resistance by dilating peripheral blood vessels.

Which nursing action would the nurse take for an infant after reporting a fever of 103.0°F (39.4°C) to the practitioner?

Removing excess clothing from the infant. Rationale: After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.

Which information will the nurse include when providing instructions to a client with the diagnosis of primary hypertension who is started on a regimen of hydrochlorothiazide?

An antihypertensive medication will likely be required for the remainder of life Rationale If medication is necessary to control primary hypertension, usually it is a lifetime requirement. Impotence may occur with some antihypertensive medications but not with hydrochlorothiazide. The medication will not be stopped; orthostatic hypotension can be controlled by a slow change of body position. The client will not adjust the dosage without the health care provider's direction.

Which condition would cause a nontender 5-cm indurated region on the upper arm of a client with type 1 diabetes who says to the nurse, "That is where I give myself insulin shots."

Lipodystrophy RATIONALE:Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits. Injections of insulin will not cause a horny growth such as a wart or callus. An allergic response will precipitate a localized or systemic inflammatory response. Hyperthermia and localized heat, erythema, and pain are associated with an infection.

Which diagnostic testing would a nurse focus on when caring for a client on isoniazid therapy for tuberculosis?

Liver Function Test Rationale Isoniazid can damage the liver enough to lead to death, so liver function should be monitored. Creatinine would be tracked for renal dysfunction, which is not a focus of isoniazid therapy because isoniazid is metabolized by the liver. Aminoglycosides can cause ototoxicity, causing hearing loss. Bedaquiline can cause prolonged QT, detected through an electrocardiogram.

which needd would be essential in clients who have dementia?

To have sameness and consistency in the environment. To have sameness and consistency in the environment is a need that is essential in clients with dementia. A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent, not the client's need. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not an essential need from clients who have this disorder; consistency is most essential.

Which statement made by a client supports the previous diagnosis of late-stage (tertiary) syphilis?

Im having trouble with my balance. Rationale: Neurotoxicity, as manifested by ataxia (balance problems), is evidence of tertiary syphilis, which may involve the central nervous system or cardiovascular system. A wart on the penis occurs in the secondary stage of syphilis. Sores all over the mouth occur in the first and secondary stage of syphilis. Sore throat with flulike symptoms occurs in the secondary stage of syphilis.

A child with a brain tumor diagnosed as an astrocytoma complains of a headache and begins to cry during a physical examination while lying in the supine position. Which factor would the nurse suspect as the most likely cause of the headache

Increased intracranial pressure caused by blood pooling in the head. A headache is a sign of increased intracranial pressure; lying supine increases blood flow to the brain, adding to the brain and tumor mass. There is no evidence that the child is fasting; however, if this were true, the child would complain of hunger and perhaps a headache at times other than when they were in the supine position. Although children at this age still suffer from a milder form of separation anxiety, the child's behavior does not indicate this type of anxiety. Although children of this age fear mutilation, the child's behavior does not indicate this kind of fear.

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. Which origin of the brain is associated with the involved nerve?

Inferior Pons

Which action would the nurse take to avoid red man syndrome when preparing to administer a vancomycin infusion?

Infuse Slowly. Rationale Vancomycin should be infused slowly to avoid the occurrence of the reaction known as "red man syndrome." Changing the IV site reduces the incidence of thrombophlebitis. Reducing the dosage is done in the setting of renal dysfunction. Administration of vitamin K is done to correct an elevated prothrombin time.

Which action would the nurse take to monitor for an adverse effect of dexamethasone prescribed for a client with adrenocortical insufficiency?

Measure blood glucose levels. Rationale Corticosteroids, such as dexamethasone, have a hyperglycemic effect, and blood glucose levels should be monitored routinely. Assessing bowel sounds is unnecessary; corticosteroids are not known to precipitate cessation of gastrointestinal activity. Monitoring deep tendon reflexes is required when administering magnesium sulfate, not dexamethasone. Although corticosteroids may increase the risk of developing an infection, routine culturing of respiratory secretions is unnecessary. Culturing respiratory secretions becomes necessary when the client exhibits adaptations of a respiratory infection.

Which action would the nurse take for a client who sustained a head injury from a fall off a ladder and has clear fluid leaking from the left ear?

Test the ear drainage with a glucose reagent strip. Rationale: If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable. Turning the client to the unaffected side will allow fluid to collect in the ear, and more importantly, manipulation of the neck while turning the client may cause further injury. Irrigating the ear canal may introduce bacterial into the open skull fracture and into the brain, causing infection. Packing sterile cotton in the ear may

Which clinical finding in a child with a diagnosis of meningitis indicates an increase in intracranial pressure? Select all that apply. One, some, or all responses may be correct.

Irritabilty Bradycardia