Med/Surg Final Prep U
A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as A. dysarthria B. receptive aphasia C. diplopia D. dysphagia.
A
A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is: A. 15% B. 25% C. Less than 5% D. Greater than 50%
A
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? A. 30-mL B. 20-mL C. 5-mL D. 10-mL
A
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route? A. nasogastric intubation B. PEG tube C. Stoma D. idk man just make some shit up the answer isnt d mmkay
A
The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest? A. continuous feedings B. intermittent feedings C. cyclic feedings D. bolus feedings
A
Which statement correctly identifies a difference between duodenal and gastric ulcers? A. Vomiting is uncommon in clients with duodenal ulcers. B. Malignancy is associated with duodenal ulcer. C. Weight gain may occur with a gastric ulcer. D. A gastric ulcer is caused by hypersecretion of stomach acid.
A
Which term most precisely refers to the incision of the common bile duct for removal of stones? A. Choledocholithotomy B. Choledochoduodenostomy C. Choledochotomy D. Cholecystostomy
A
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? A. Pyrosis B. Dyspepsia C. Dysphagia D. Odynophagia
A
Which tube is a nasoenteric feeding tube? A. Dobbhoff B. Levin C. Salem D. Sengstaken-Blakemore
A
Which value indicates a normal intracranial pressure (ICP)? A. 5 mm Hg B. 12 mm Hg C. 17 mm Hg D. 21 mm Hg
A
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. A. Administering prescribed antipyretics B. Maintaining aseptic technique with an intraventricular catheter C. Elevating the head of the bed to 90 degrees D. Frequent oral care E. Encouraging deep breathing and coughing every 2 hours
A, B, D
Several clinical manifestations are associated with a tumor of the head of the pancreas. Choose all that apply. A. Dark urine B. Amber-colored urine C. Clay-colored stools D. Dark-colored stools E. Jaundice
A, C, E
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. A. Enlarged liver size B. Accelerated behaviors and mental processes C. Excess storage of vitamin C D. Ascites E. Hemorrhoids
A, D, E
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: A. muscular B. unknown C. vasodilating agents D. endocrine
B
A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? A. H2-receptor antagonist and two antibiotics B. Proton-pump inhibitor and two antibiotics C. H2-receptor antagonist, proton-pump inhibitor, and an antibiotic D. Proton-pump inhibitor, an antibiotic, and bismuth salts
B
A patient diagnosed with IBS is advised to eat a diet that is: A. Restricted to 1,200 calories/day. B. High in fiber. C. Sodium-restricted. D. Low in residue.
B
A patient has been diagnosed with Zenker's diverticulum. What treatment does the nurse anticipate educating the patient about? A. A low-residue diet B. Surgical removal of the diverticulum C. Radiation therapy D. Chemotherapeutic agents
B
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A. reduce cellular metabolic demand B. dehydrate the brain and reduce cerebral edema C. control fever D. control shivering.
B
Cerebral edema peaks at which time point after intracranial surgery? A. 12 hours B. 24 hours C. 48 hours D. 72 hours
B
Cholesterol stones account for what percentage of cases of gallbladder disease in the United States? A. 60% B. 75% C. 25% D. 15%
B
The Monro-Kellie hypothesis explains A. Why the client is awake but lacks consciousness, without cognitive or affective mental function. B. The dynamic equilibrium of cranial contents. C. The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. D. Nonresponse of the brain to the environment.
B
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? A. Neglect of the side opposite to the hemisphere affected B. Neglect of the left side C. Expressive aphasia D. Inability to move the right arm
B
Which is indicative of a right hemisphere stroke? A. Altered intellectual ability B. Spatial-perceptual deficits C. Slow, cautious behavior D. Aphasia
B
Which is the initial diagnostic test for a stroke? A. Electrocardiography B. Noncontrast computed tomography C. Transcranial Doppler studies D. Carotid Doppler
B
Which statement reflects nursing management of the client with expressive aphasia? A. Speak slowly and clearly to assist the client in forming the sounds B. Encourage the client to repeat sounds of the alphabet C. Speak clearly to the client in simple sentences, and use gestures or pictures when able D. Frequently reorient the client to time, place, and situation
B
The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition? A. MRI B. CT C. ERCP D. Ultrasound
C
The nurse recognizes that medium-length nasoenteric tubes are used for A. decompression B. emptying C. feeding D. aspiration
C
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: A. pancreatitis B. acute cholecystitis C. hepatitis B D. hepatitis A
B
Which of the following is accurate regarding regional enteritis? A. Severe bleeding B. Exacerbations and remissions C. Severe diarrhea D. Fistulas are common
B
Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition? A. implanted ports B. peripherally inserted C. central catheters D. tunneled catheters E. nontunneled catheters
E
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? A. Seasonal changes B. Reproductive hormone fluctuations C. Medications D. Specific food chemicals
A
A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? A. High-dose corticosteroids B. Paracentesis C. Azathioprine D. Liver transplantation
A
Which is a true statement regarding regional enteritis (Crohn's disease)? A. The clusters of ulcers take on a cobblestone appearance. B. It has a progressive disease pattern. C. The lesions are in continuous contact with one another. D. It is characterized by pain in the lower left abdominal quadrant.
A
Which is a true statement regarding the nursing considerations in administration of metronidazole? A. It leaves a metallic taste in the mouth. B. It may cause weight gain. C. Metronidazole decreases the effect of warfarin. D. The drug should be given before meals.
A
A nurse cares for an older adult client and teaches the client about age-related changes of the biliary tract. What statements will the nurse include when discussing age-related changes that occur in the pancreas of the older adult? Select all that apply. A. "The pancreas develops fibrous material with age." B. "The pancreas decreases secretion of enzymes with age." C. "The pancreas develops fatty deposits with age." D. "The pancreas enlarges and atrophies with age." E. "The pancreas decreases bicarbonate secretion with age.
A, B, C, E
A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? A. Venous congestion B. Arterial thrombosis C. Infection D. Possible necrosis
B
Which position should be used for a client undergoing a paracentesis? A. Trendelenburg B. Prone C. Upright at the edge of the bed D. Supine
C
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. A. Pain and stiffness of the extremities B. Low white blood cell (WBC) count C. Purpura of hands and feet D. Cloudy cerebral spinal fluid E. Low red blood cell (RBC) count F. Low antidiuretic hormone (ADH) levels
C, D
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? A. Stent placement B. Removal of the carotid artery C. Percutaneous transluminal coronary artery angioplasty D. Carotid endarterectomy
D
A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see? A. Lactic acidosis B. Hypoglycemia C. Hyperkalemia D. Constipation
D
Clinical manifestations of common bile duct obstruction include all of the following except: A. Pruritus B. Clay-colored feces C. Jaundice D. Amber-colored urine
D
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? A. Assist the client to the floor, in a side-lying position, and protect him with linens. B. Put a padded tongue blade into the client's mouth and restrain his extremities. C. Record the type of seizure and the time that it occurred. D. Initiate the code team response.
A
A client is having a tonic-clonic seizure. What should the nurse do first? A. Take measures to prevent injury. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Elevate the head of the bed.
A
A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse? A. Attaches the fat emulsion tubing to a Y connector close to the infusion site B. Stops the admixture while the fat emulsion infuses C. Starts a peripheral IV site to administer the fat emulsion D. Connects the tubing for the fat emulsion above the 1.5 micron filter
A
A client who was recently diagnosed with carcinoma of the pancreas and is having a procedure in which the head of the pancreas is removed. In addition, the surgeon will remove the duodenum and stomach, redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is this client having performed? A. radical pancreatoduodenectomy B. cholecystojejunostomy C. distal pancreatectomy D. total pancreatectomy
A
An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? A. 45 mg B. 90 mg C. 85 mg D. 50 mg
A
A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply. A. Difficulty swallowing B. Respiratory distress C. Increasing ICP D. Seizure activity
A, B
A client experienced surgical resection of a tumor of the esophagus. After recovery from the anesthesia, what will the nurse include in the postoperative care plans? Select all that apply. A. Assess lung sounds every 4 hours and prn. B. Maintain the client in a side-lying position. C. Verify rhythm on the cardiac monitoring system. D. Replace the nasogastric tube if the tube becomes dislodged. E. Monitor drainage in the closed chest drainage system.
A, C, E
The nurse is reviewing the chart of a client with swallowing problems. Which factors would raise suspicion that the client has cancer of the esophagus? Select all that apply. A. Male gender B. Caucasian race C. Previous treatment for gastroesophageal reflux disease D. Age 72 years E. Smoking history of 20 years
A, C, E
The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply. A. Weigh the client every day. B. Cover insertion site with a transparent dressing that is changed daily. C. Use clean technique for all catheter dressing changes. D. Check blood glucose level every 6 hours. E. Document intake and output.
A, D, E
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Mannitol C. Half-normal saline (0.45% NSS) D. One-third normal saline (0.33% NSS)
B
A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Suction the mouth during the convulsion. B. Protect the client from injury. C. Insert a tongue blade between the teeth. D. Restrain the client during the seizure.
B
The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? A. Vomiting B. Watery diarrhea C. Ringing in the ears D. Asterixis
B
A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome? A. Lymphadenopathy B. Decreased intestinal lactose C. Steatorrhea D. Folate deficiency
C
What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? A. bolus feeding B. intermittent feeding C. continuous feedings D. cyclic feeding
C
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse? A. Irrigate the client's NG tube. B. Notify the health care provider. C. Assess the client's abdomen and vital signs. D. Place the client in the high-Fowler's position.
C
Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? A. MODS B. Tetany C. Pancreatic necrosis D. Shock
C
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. A. Assess for patency of the peripheral intravenous site B. Administer the intravenous antibiotic in the same tubing as the parenteral nutrition C. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel D. Place a 1.5-micron filter on the tubing E. Ensure availability of an infusion pump
C, D, E
A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority? A. Fatigue B. Excess fluid volume C. Imbalanced nutrition: Less than body requirements D. Ineffective breathing pattern
D
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? A. The CPP is within normal limits. B. The CPP reading is inaccurate. C. The CPP is high. D. The CPP is low.
D
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: A. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. B. Feedings can be administered with the patient in the recumbent position. C. The patient cannot experience the deprivational stress of not swallowing. D. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.
D
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every A. 12 hours B. 24 hours C. hour D. shift
D
The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply. A. Use of humidification B. Oral hygiene C. Follow-up medical appointment D. Follow-up dental appointment
A, B, C, D
A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. A. Irritating foods B. Overuse of aspirin C. DASH diet D. Ingestion of strong acids E. Participation in highly competitive sports
A, B, D
When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) A. Administering parenteral opioid analgesics as ordered B. Encouraging bed rest to decrease the metabolic rate C. Administering prophylactic antibiotics D. Assisting the patient into the prone position E. Withholding oral feedings to limit the release of secretin
A, B, E
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. A. Rabeprazole (AcipHex) B. Lansoprazole (Prevacid) C. Nizatidine (Axid) D. Famotidine (Pepcid) E. Esomeprazole (Nexium)
A, B, E
Which of the following are functions of saliva? Select all that apply. A. Protection against harmful bacteria B. Metabolism C. Digestion D. Lubrication E. Elimination
A, C, D
PLANTAR FLEXED, FLEXED, PRONATED, EXTENDED, ADDUCTED prognosis: A. fatal B. poor C. good D. excellent
B
The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis? A. Sharp, stabbing pain in the left lower quadrant of the abdomen B. Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back C. Dull pain, points to epigastric area D. Severe abdominal pain that radiates to the right shoulder
B
The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis? A. Pancreatitis causes alterations to hemoglobin, impairing oxygenation. B. Pancreatitis can elevate the diaphragm and alter the breathing pattern. C. Pancreatitis can atrophy the diaphragm and alter the breathing pattern. D. Pancreatitis causes thickening of pulmonary secretions, impairing oxygenation.
B
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? A. Decerebrate B. Decorticate C. Flaccid D. Rigid
C
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? A. 60 minutes B. 80 minutes C. 30 minutes D. 15 minutes
C
Which is the most common motor dysfunction seen in clients diagnosed with stroke? A. Hemiparesis B. Diplopia C. Ataxia D. Hemiplegia
D
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? A. Muscle spasms B. Sleep pattern C. Mood and affect D. Appetite
A
A client is receiving continuous tube feedings at 75 mL/hr. The nurse has checked the residual volume 4 hours ago as 250 mL. The nurse now assesses the residual volume as 325 mL. The first action of the nurse is to A. Notify the physician B. Stop the continuous feeding C. Discard the residual volume D. Decrease the rate to 40 mL/hr
A
A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A. Migraines often coincide with menstrual cycle. B. Headaches are the most common type of reported pain. C. Tension headaches are easier to treat. D. Cluster headaches can cause severe debilitating pain.
A
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client uses a mirror to inspect the skin. B. The client leaves the side rails down. C. The client hangs the left arm over the side of the wheelchair. D. The client repositions only after being reminded to do so.
A
PLANTAR FLEXED, INTERNALLY ROTATED, FLEXED, ADDUCTED. Which posturing is the patient exhibiting? A. Decorticate B. Tonic clonic C. Decerebrate D. Flaccidity
A
A client is in the initial stages of oral cancer diagnosis and is frightened about the side effects of treatment and subsequent prognosis. The client has many questions regarding this type of cancer and asks where oral cancer typically occurs. What is the nurse's response? A. base of the tongue B. floor of the mouth C. roof of the mouth D. inside of the cheeks
B
A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________. A. McBurney's sign; acute appendicitis B. Rovsing's sign; acute appendicitis C. Rovsing's sign; perforation D. McBurney's sign; perforation
B
A client with gastric cancer is scheduled to undergo a Billroth II procedure. The client's spouse asks how much of the client's stomach will be removed. What would be the most accurate response from the nurse? A. Approximately 25% B. Approximately 75% C. The amount will depend on the client's weight. D. Approximately 50%
B
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? A. 150 to 200 mL/h B. More than 200 mL/h C. 100 to 150 mL/h D. 50 to 100 mL/h
B
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Position the client with the head turned toward the side of the brain tumor. B. Administer stool softeners. C. Encourage coughing and deep breathing. D. Provide sensory stimulation.
B
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with: A. Gastroenteritis. B. Paralytic ileus. C. Complete bowel obstruction. D. Crohn's disease.
B
A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of: A. Generalized fatigue. B. Diplopia. C. Dysphoria. D. Facial muscle weakness.
B
A nurse is caring for a client with mild acute pancreatitis. Which health care provider prescriptions will the nurse question as it relates to evidence based practices in the treatment of acute pancreatitis? Select all that apply. A. Nasogastric tube to intermittent wall suction for relief of nausea. B. Nasogastric tube to intermittent wall suction for removal of gastric secretions. C. Initiate parenteral feedings first and advance to enteral feedings as tolerated. D. Full liquid diet as tolerated. E. Enteral feedings per registered dietitian recommendations.
B, C, D
A client has a family history of stomach cancer. Which factor would further increase the client's risk for developing gastric cancer? Select all that apply. A. Caucasian ancestry B. Previous infection with H. pylori C. Female gender D. Age 55 years E. High intake of fruits and vegetables
B, D
A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? A. Buccal B. Submandibular C. Parotid D. Sublingual
C
What is the most appropriate nursing diagnosis for the client with acute pancreatitis? A. Decreased cardiac output B. Ineffective gastrointestinal tissue perfusion C. Deficient fluid volume D. Excess fluid volume
C
What is the most common cause of small-bowel obstruction? A. Volvulus B. Hernias C. Adhesions D. Neoplasms
C
Which insult or abnormality can cause an ischemic stroke? A. Intracerebral aneurysm rupture B. Trauma C. Cocaine use D. Arteriovenous malformation
C
Which is an accurate statement regarding gastric cancer? A. Most gastric cancer-related deaths occur in people younger than 40 years. B. A diet high in smoked foods and low in fruits and vegetables may decrease the risk of gastric cancer. C. The incidence of stomach cancer continues to decrease in the United States. D. Females have a higher incidence of gastric cancers than males.
C
Which mouth condition is associated with HIV infection? A. Krythoplakia B. Candidiasis C. Kaposi sarcoma D. Stomatitis
C
Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? A. Limiting I.V. fluids, as ordered, to decrease cardiac workload B. Administering meperedine, as ordered, to relieve severe pain C. Withholding all oral intake, as ordered, to decrease pancreatic secretions D. Keeping the client supine to increase comfort
C
Which of the following is the most common type of diverticulum? A. Epiphrenic B. Midesophageal C. Zenker's diverticulum D. Intramural
C
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? A. Providing generous servings at mealtime B. Providing the client with plenty of P.O. fluids C. Limiting I.V. fluid intake according to the physician's order D. Reserving an antecubital site for a peripherally inserted central catheter (PICC)
D
A nurse is teaching a client who has experienced an episode of acute gastritis. The nurse knows further education is necessary when the client makes which statement? A. "I should limit alcohol intake, at least until symptoms subside." B. "Once I can eat again, I should stick with bland foods." C. "I should feel better in about 24 to 36 hours." D. "My appetite should come back tomorrow."
D
A patient has been NPO for two days anticipating surgery which has been repeatedly delayed. In addition to risks of nutritional and fluid deficits, the nurse determines that this patient is at the greatest risk for: A. physical injury B. confusion C. ineffective social interaction D. altered oral mucous membranes.
D
A patient has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube? A. Milk B. Distilled water C. High-calorie liquids D. 10% glucose and tap water
D
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? A. 0 to 10 mm Hg B. 8 to 15 mm Hg C. 25 to 40 mm Hg D. 20 to 30 mm Hg
A
The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal? A. Maintaining skin integrity B. Beginning a bowel program to establish continence C. Instituting a diet high in fiber and increase fluid intake D. Determining the need for surgical intervention to correct the problem
A
The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern? A. The client's hands flap back and forth when the arms are extended. B. The client reports nausea and anorexia. C. The skin on the client's abdomen has multiple spider-shaped blood vessels. D. The client has gained 2 kg from the previous day.
A
A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxy-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give? A. 6 to 8 months B. 6 to 12 months C. 3 to 5 months D. 1 to 2 months
B
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? A. Being female B. Being obese C. Having bronchial asthma D. Being white
B
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? A. Hypertension B. Vasoconstriction C. Vasodilation D. Increased PaO
C
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? A. Reposition the tube. B. Increase the suction level. C. Notify the health care provider. D. Irrigate the tube.
C
A client who is being treated for pyloric obstruction has a nasogastric (NG) tube in place to decompress the stomach. The nurse routinely checks for obstruction which would be indicated by what amount? A. 350 mL B. 250 mL C. 450 mL D. 150 mL
C
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? A. 30 minutes B. 2 hours C. 1 hour D. 90 minutes
C
A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control? A. The client maintains skin integrity. B. The client verbalizes a manageable level of discomfort. C. The client expresses positive feelings about himself. D. The client exhibits signs of adequate GI perfusion.
D
A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem? A. Diverticulitis B. Appendicitis C. Rectal fissures D. Bowel perforation
D
The nurse knows that the serum amylase concentration returns to normal within which time frame? A. 12 hours B. 24 hours C. 36 hours D. 48 hours
D
A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? A. Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. B. The nurse should do nothing because she is responsible only for inpatient care. C. Suggest that the family members speak with the physician about their concerns. D. Contact the appropriate agencies so that they can provide care after discharge.
A
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? A. This is significant for poor neurologic outcomes. B. The patient has liver failure. C. The patient has new onset diabetes. D. The patient has developed diabetes insipidus due to the location of the stroke.
A
The client has a chancre on the lips. What instruction should the nurse provide? A. Take measures to prevent spreading the lesion to other people. B. Gargle with an antiseptic solution. C. Avoid foods that could irritate the lesion. D. Apply warm soaks to the lip.
A
To meet the sensory needs of a client with viral meningitis, the nurse should: A. Minimize exposure to bright lights and noise. B. Avoid physical contact between the client and family members. C. Increase environmental stimuli. D. promote an active range of motion.
A
What is the most common cause of small-bowel obstruction? A. Adhesions B. Hernias C. Neoplasms D. Volvulus
A
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? A. Tip of patient's nose B. Tip of the xiphoid process C. Base of the neck D. Tragus of the ear
A
Which of the following is the most common complication associated with peptic ulcer? A. Hemorrhage B. Vomiting C. Elevated temperature D. Abdominal pain
A
Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. A. Ensure access to a language board when communicating with the client. B. Encourage the client to walk with feet wide apart. C. Establish a voiding time schedule. D. Obtain daily weights to monitor weight gain.
A, B, C
Which of the following are characteristics associated with the Zollinger-Ellison syndrome (ZES)? Select all that apply. A. Severe peptic ulcers B. Gastrin-secreting tumors of the pancreas C. Extreme gastric hyperacidity D. Hypocalcemia E. Constipation
A, B, C
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply. A. Jaundice B. Ecchymoses C. Cyanosis of the lips D. Aphthous stomatitis E. Petechiae
A, B, E
A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options. A. Permanent neurologic dysfunction B. Insomnia C. Impaired cellular activity D. Death E. Seizures
A, C, D
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? A. Up to 1 week B. 1 to 3 days C. Up to 24 hours D. Up to 2 weeks
B
Which of the following liver function studies is used to show the size of abdominal organs and the presence of masses? A. Magnetic resonance imaging B. Ultrasonography C. Angiography D. Electroencephalogram
B
The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? A. Eliminating cucumbers and other foods with seeds. B. Avoiding steamed foods. C. Avoiding chocolate and coffee. D. Eliminating spicy foods.
C
Which of the following diagnostic studies definitely confirms the presence of ascites? A. Abdominal x-ray B. Computed tomography of abdomen C. Colonoscopy D. Ultrasound of liver and abdomen
D
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? A. Perform stretching exercises and frequent position change. B. Apply cool or warm cloth to head or eyes. C. Avoid certain foods. D. Eliminate use of bright lights when working.
A
Which of the following refers to a bacterial or viral infection of the salivary glands? A. Sialadenitis B. Stomatitis C. Mumps D. Parotitis
A
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: A. alcohol abuse and a history of acute renal failure. B. alcohol abuse and smoking C. history of hemorrhoids and smoking. D. a sedentary lifestyle and smoking.
B
A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? A. Subarachnoid hemorrhage B. Intracerebral hemorrhage C. Hemorrhage due to an aneurysm D. Arteriovenous malformation
B
After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? A. "I'll need to drink at least eight glasses of water a day." B. "I'll have to wear an external collection pouch for the rest of my life." C. "I should eat foods from all the food groups." D. "I'll have to catheterize my pouch every 2 hours."
B
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients? A. Increased intestinal motility B. Decreased abdominal strength C. Decreased production of hydrochloric acid D. Increased intestinal bacteria
B
The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention A. Change the transparent dressing every 3 days. B. Wear a face mask during dressing changes. C. Use clean gloves when providing site care. D. Assess the PICC insertion site daily.
B
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? A. The day before the patient is discharged B. The day the patient has the stroke C. After the nurse has received the discharge orders D. After the patient has passed the acute phase of the stroke
B
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as A. normal B. decerebrate C. decorticate D. flaccid
B
Which type of jaundice seen in adults is the result of increased destruction of red blood cells? A. Nonobstructive B. Hemolytic C. Hepatocellular D. Obstructive
B
While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A. Migraine B. Cluster C. Sinus D. Tension
B
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: A. Place the client on fluid restrictions. B. Use a condom catheter instead of an invasive one. C. Increase the frequency of the catheterizations. D. Insert an indwelling urinary catheter.
C
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: A. place the client in a private room B. wear a gown when providing personal care for the client C. wash her hands after touching the client D. wear a mask when handling the client's bedpan
C
The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond? A. Low-sodium, high-potassium, low-fat diet B. High-carbohydrate, high-protein, low-fat diet C. High-carbohydrate, low-protein, low-fat diet D. Low-carbohydrate, high-potassium diet
C
A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen? A. "My ulcer will heal because these medications will kill the bacteria." B. "These medications will coat the ulcer and decrease the acid production in my stomach." C. "I should take these medications only when I have pain from my ulcer." D. "The medications will kill the bacteria and stop the acid production."
D
A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver? A. Convert urea into ammonia B. Break down coagulation factors C. Breakdown amino acids D. Excrete bile
D
A morbidly obese client asks the nurse if medications are available to assist with weight loss. The nurse knows that the client would not be a candidate for phentermine if the following is part of the client's health history: A. Use of lithium B. Diabetes C. Peptic ulcer disease D. Coronary artery disease
D
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 6 B. 9 C. 15 D. 3
D
A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine? A. Roof of the mouth next to the incisors B. Dorsum of the tongue C. Posterior segment of the tongue near the uvula D. Buccal mucosa next to the upper molars
D
Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? A. Allowing a clear liquid diet during the acute phase B. Maintaining a high-Fowler's position C. Administering oral analgesics around the clock D. Providing intensive insulin therapy
D
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Ataxia B. Diplopia C. Alopecia D. Gingival hyperplasia
D
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. A. Major abdominal surgery within 10 days B. Intracranial hemorrhage C. Systolic BP less than or equal to 185 mm Hg D. Ischemic stroke E. Age 18 years or older
A, B
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? A. Altered Nutrition: Less Than Body Requirements B. Risk for Fluid Volume Deficit C. Impaired Swallowing D. Risk for Electrolyte Imbalance
C
A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? A. tachycardia and bradypnea B. bradycardia and tachypnea C. tachycardia and tachypnea D. bradycardia and bradypnea
C
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? A. Take the client's blood pressure. B. Ask the client if he has a headache. C. Ask the client if he has trouble breathing. D. Place antiembolism stockings on the client.
C
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer? A. Krythoplakia B. Chancre C. Actinic cheilitis D. Herpes simplex 1
C
The nurse is creating a discharge plan of care for a client with a peptic ulcer. The nurse tells the client to avoid A. skim milk. B. octreotide. C. decaffeinated coffee. D. acetaminophen.
C
The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes? A. The tube is less expensive B. The tube is shorter C. The tube is radiopaque D. The tube can be connected to suction and others cannot
C
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? A. 6 B. 10 C. 8 D. 4
D
The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a A. implanted port B. nontunneled central catheter C. peripherally inserted central catheter D. tunneled central catheter.
B
After undergoing a liver biopsy, a client should be placed in which position? A. Supine position B. Semi-Fowler's position C. Right lateral decubitus position D. Prone position
C
The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? A. Assess for signs and symptoms of infection. B. Administer acetaminophen per orders. C. Provide ventriculostomy care. D. Inspect the ICP monitor to ensure it is working properly.
B
The nurse is caring for a patient who has been diagnosed with gastritis. To promote fluid balance when treating gastritis, the nurse knows that what minimal daily intake of fluids is required? A. 2.0 L B. 1.5 L C. 2.5 L D. 1.0 L
B
The nurse is caring for a client receiving chemotherapy. For which mouth conditions associated with HIV infection should the nurse assess? Select all that apply. A. Krythoplakia B. Kaposi sarcoma C. Candidiasis D. Stomatitis
B, D
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? A. Place the wheelchair on the client's left side when transferring him into a wheelchair. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Provide close supervision because of the client's impulsiveness and poor judgment. D. Support the right arm with a sling or pillow to prevent subluxation.
C
A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to A. Presence of diabetes mellitus B. Dietary intake of fat C. Age D. Cigarette smoking
C
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? A. Have someone go to the pharmacy to obtain the new solution. B. Begin an infusion of normal saline in another site to maintain hydration. C. Hang a solution of dextrose 10% and water until the new solution is available. D. Slow the current infusion rate so that it will last until the new solution arrives.
C
A patient with epilepsy is having a seizure. Which of the following should the nurse do after the seizure? A. Pry the patient's mouth open to allow a patent airway. B. Place a cooling blanket beneath the patient. C. Keep the patient to one side. D. Help the patient sit up.
C
A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? A. Staff nurse B. Social worker C. Enterostomal nurse D. Clinical educator
C
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? A. Giving him a barbiturate B. Placing him on mechanical ventilation C. Performing a lumbar puncture D. Elevating the head of his bed
C
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: A. Lower arterial pH. B. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. C. Promote carbon dioxide elimination. D. Prevent respiratory alkalosis.
C
Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution? A. D10W B. D5W C. 0.9% NS D. 0.45% of NS
C
The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is A. Elevate the head of the bed. B. Position client flat in bed. C. Auscultate lung sounds. D. Consult with the healthcare provider.
C
The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse? A. Catch up with the next bag when it arrives. B. Request a new bag from the pharmacy department. C. Infuse a solution containing 10% dextrose and water. D. Flush the line with 10 mL of sterile saline.
C
The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do? A. Stop the infusion and flush the line B. Hang normal saline with potassium C. Hang 10% dextrose and water D. Hang 5% dextrose and water
C
The nurse is assessing an 80-year-old client for signs and symptoms of gastric cancer. The nurse differentiates which as a sign/symptom of gastric cancer in the geriatric client, but not in a client under the age of 75? A. Ascites B. Abdominal mass C. Agitation D. Hepatomegalia
C
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? A. Elevate the foot of the bed on 6- to 8-inch blocks B. Minimize intake of caffeine, beer, milk, and foods containing peppermint or spearmint C. Eat a low-carbohydrate diet D. Avoid eating or drinking 2 hours before bedtime
D
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A. Tendency to distractibility B. Neglect of objects and people on the left side C. Impairment of long-term memory D. Left-sided hemiplegia E. Hyperaware of deficits
A, B, D
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. A. Bradypnea B. Pupillary constriction C. Hypertension D. Bradycardia E. Tachycardia
A, C, D
The causes of acquired seizures include what? (Select all that apply.) A. Metabolic and toxic conditions B. Hypernatremia C. Drug and alcohol withdrawal D. Brain tumor E. Cerebrovascular disease
A, C, D, E
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? A. Assess for weight loss. B. Administer corticosteroids as ordered. C. Document signs and symptoms of inflammation. D. Give acetaminophen per orders.
B
The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for? A. Abdominal radiography B. Defecography C. Kidneys, ureters, bladder (KUB) D. Colonic transit studies
B
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? A. Maintain hydration by drinking eight glasses of fluid a day B. Apply warm or cool cloths to the forehead or back of the neck C. Use pressure-relieving pads or a similar type of mattress D. Perform the Heimlich maneuver
B
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? A. Hypotension and bradycardia B. Hypotension and tachycardia C. Rising blood pressure and bradycardia D. Hypertension and narrowing pulse pressure
B
A nurse is caring for a client who had an ileo conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation? A. Clear mucus mixed with yellow urine drained from the appliance bag B. Beefy red stoma site C. Red, sensitive skin around the stoma site D. Stoma site not sensitive to touch
C
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Elevating the head of the bed to 30 degrees B. Monitoring for seizure activity C. Maintaining a patent airway D. Administering a stool softener
C
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A. Isosorbide B. Urea C. Mannitol D. Glycerin
C
A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? A. Developing no acute complications from the pancreatitis B. Achieving adequate fluid and electrolyte balance C. Maintaining satisfactory pain control D. Maintaining normal respiratory function
D
A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: A. urine output B. abdominal girth C. stool frequency D. level of consciousness (LOC)
D
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent? A. Bismuth subsalicylate B. Bisacodyl C. Kaolin and pectin D. Loperamide
D
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? A. Seizures B. Change in level of consciousness C. Vomiting D. Vector bites
D
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A. Damage to the olfactory nerve B. Damage to the vagal nerve C. Damage to the facial nerve D. Damage to the optic nerve
D
The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred? A. Infection has developed. B. A drain may have become dislodged. C. The surgical wound has begun to bleed. D. Wound dehiscence has occurred.
D
The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired? A. Protein synthesis B. Fat digestion C. Protein digestion D. Carbohydrate digestion
D
Which set of symptoms characterize Korsakoff syndrome? A. Tremor, rigidity, and bradykinesia B. Severe dementia and myoclonus C. Choreiform movement and dementia D. Psychosis, disorientation, delirium, insomnia, and hallucinations
D
