Midterm medsurg ati

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect?

Petechiae Rationale: A manifestation of advanced cirrhosis is petechiae due to impaired coagulation from a dysfunctional liver.

nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Spider angiomas Rationale: Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis.

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

"Wash your hair with a mild protein shampoo." Rationale: Clients who have SLE are prone to hair loss and should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is teaching a client who has a new prescription of allopurinol for the treatment of gout. Which of the following instructions should the nurse include?

"Drink 2 liters of fluid each day while taking the medication." Rationale: An adverse effect of allopurinol is renal damage. The client should drink 2 L of fluids a day to decrease the risk of renal damage.

A nurse is teaching a client who is starting to take methotrexate to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Drink at least 2 liters of water daily. "Rationale: The client should drink 2 to 3 L of water per day because methotrexate can cause kidney damage. Adequate hydration optimizes drug excretion and helps prevent renal damage.

A nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching?

"Fibromyalgia causes joint inflammation." Rationale: Clients who have fibromyalgia may report joint discomfort. However, fibromyalgia is a noninflammatory disorder and does not cause joint inflammation.

A nurse is teaching a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client indicates a need for further teaching?

"I can take my morning dose of metformin." Rationale: Metformin must be withheld for 48 hr prior to receiving an IV contrast containing iodine. This type of contrast can alter renal function and cause renal failure. The client's BUN and creatinine should be closely monitored after the procedure.

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

"I give the insulin injections in my abdominal area." Rationale: The client should give insulin injections in one anatomic area for consistent day-to-day absorption. The abdomen is the area for fastest absorption.

A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

"I should buy new shoes late in the day." Rationale: The client's feet are larger later in the day. Therefore, this is the best time to buy new shoes.

A nurse is creating home instructions for a client who has an immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid people who have just received an immunization." Rationale: The client should avoid people who received a vaccination, especially a live vaccine, to prevent contracting the disease.

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

"I will feel shaky." Rationale: Manifestations of hypoglycemia include feeling shaky and nervous.

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

"I will limit my alcohol intake." Rationale: A client who has gout should limit alcohol consumption, which is known to cause a gouty attack by inhibiting excretion of uric acid and leading to its buildup. However, clients should be encouraged to increase their fluid intake to help prevent formation of urinary stones.

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

"I'll check my feet every day for sores and bruises". Rationale: The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

"I'll check my feet every day for sores and bruises." Rationale: The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

"I've been taking an antacid to help with indigestion." Rationale: NSAIDs, like naproxen, can cause serious adverse gastrointestinal reactions such as ulceration, bleeding, and perforation. Warning manifestations such as nausea or vomiting,gastrointestinal burning, and blood in the stool reported by the client require further investigation by the nurse. The client might be taking an antacid because he is experiencing one or more of these manifestations.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

"It is caused by the lack of production of aldosterone by the adrenal gland." Rationale: Addison's disease is caused by a lack of production of the adrenocorticotropic hormones(cortisol and aldosterone) by the adrenal gland.

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching?

"Low-impact aerobics can help reduce episodes of pain." Rationale: The nurse should reinforce that clients who have fibromyalgia can help reduce pain through regular low-impact aerobics, such as walking, swimming, and biking.

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

"Maintain stable blood glucose levels." Rationale: Keeping blood glucose under control is the client's best protection against long-term complications of diabetes, since increased blood sugar contributes to neuropathic disease, and microvascular complications such as retinopathy and nephropathy, as well as to macrovascular complications.

A nurse is teaching with a client about taking high doses of oral glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Monitor for compression fractures of the back and neck." Rationale: High-dose, long-term use of glucocorticoids can result in bone loss in the back and neck within weeks of starting the medication. Clients experience an increase in parathyroid hormone, which causes calcium to move out of the bones can result in fractures.

A client asks their nurse about the differences between Type 1 and Type 2 diabetes. What response is best?

"People with type 1 diabetes do not produce insulin because their beta cells are not working properly; People with type 2 diabetes produce insulin but the body cannot use the insulin properly.

A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?

"Prevent the spread of infection with good household cleaning practices." Rationale: The client should follow standard precautions and use a 1:10 solution of bleach to disinfect areas that come into contact with blood and body fluids.

A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include?

"Store the current bottle of insulin at room temperature." Rationale: The nurse should instruct the client to keep the bottle of insulin she is currently using at room temperature to minimize painful injections. The client should refrigerate unused bottles of insulin to protect the quality of the medication.

A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Take the medication with a meal." Rationale: The client should take metformin with a meal to avoid hypoglycemia and GI upset, and to provide the most absorption of the medication.

A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?

"Take the medication with milk." Rationale: Betamethasone should be administered with milk or food to prevent gastric irritation.

A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse make?

"The intra-articular deposition of urate crystals causes inflammation." Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and cause inflammation and pain.

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?

"They are going to examine my gallbladder and ducts." Rationale: With oral cholangiography, the client receives an iodide-containing contrast agent 10 to 12 hr before the procedure. Then, the examiner can evaluate the gallbladder for filling, contracting,and emptying and can also see the gallstones on the x-rays.

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

"Your body has insulin resistance and decreased insulin secretion." Rationale: A client genetically susceptible can develop Type 2 diabetes mellitus when obesity and physical inactivity lead to insulin resistance at cells as well as decreased secretion of insulin by pancreatic beta-cells.

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

0.9% sodium chloride IV bolus Rationale: The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs.

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?

0745 Rationale: Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30minutes. There are circumstances when this lag time guide can be adjusted.

A nurse is providing teaching to a client who has a diabetes mellitus about carbohydrate intake needs when exercising. Which of the following foods should the nurse include as containing a 15 g serving of carbohydrates?

1 cup milk Rationale: The nurse should instruct the client that 1 cup of milk contains 15 g of carbohydrates.

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

6.3% Rationale: The client who has diabetes mellitus needs to manage activity and diet while monitoring blood glucose levels. High levels of blood glucose cause damage to the macro and microcirculation,affecting such things as eyesight and kidney function. The goal for a client who has diabetes mellitus is to keep the HbA1c values at 6.5% or less.

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

A client who has a phosphate of 5.7 mg/dL Rationale: This level is above the expected reference range of 3.0 to 4.5 mg/dL. Phosphorus levels are increased in a client who has hypoparathyroidism.

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

A client who has multiple tattoos

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks. Rationale: A "butterfly" rash that is dry, red, and raised is characteristic of SLE.

A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients.Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

A phlebotomist who collects blood from clients who have HIV Rationale: The greatest risk for exposure to HIV is from a needle stick; therefore, the phlebotomist who collects blood is at greatest risk.

A nurse is preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should plan to include which of the following findings as a manifestation of SLE?

A raised rash Rationale: A dry, raised rash (butterfly rash) on the face or on sun exposed areas of the body is a manifestation of SLE.

A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect?

Client report of numbness in his hands Rationale: Numbness and tingling in the client's hands and feet are manifestations of hypoparathyroidism due to hypocalcemia.

A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity (AMI). Which of the following information should the nurse confirm about AMI?

AMI is mediated by antibodies produced by B-lymphocytes. Rationale: AMI is mediated by antibodies produced by B-lymphocytes in response to an invading allergen or antigen.

A nurse is admitting a client who has acute pancreatitis. Which of the following provider orders should the nurse anticipate?

Client should remain NPO

A nurse observes mild hand tremors in a client who has diabetes mellitus. Which of the following actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL?

Administer 15 g of carbohydrates. Rationale: The first step in preventing the client's blood glucose level from dropping further is to administer 15 to 20 g of carbohydrates. A client who is awake and can swallow can consume carbohydrates, such as glucose tablets or glucose gel, 120 mL (4 oz) of orange juice, 240 mL(8 oz) of skim milk, 6 saltine crackers, 3 graham crackers, or 6 to 10 hard candies.

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Administer furosemide (lasix);Measure the client's abdominal girth.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Administer lactulose

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)

Alopecia, Moon face, Purple striations, and Buffalo hump

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

Amylase Rationale: Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth,stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.

A nurse is reviewing the laboratory results of an adolescent client and notes a WBC count of 18,000/mm³ with increased immature neutrophils (bands). Which of the following is the appropriate analysis of the results?

An acute infectious process Rationale: The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process.

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

Assess for hypoglycemia 1 to 3 hrs after the insulin injection. Rationale: The nurse should assess for hypoglycemia for 1 to 3 hr, not 4 hr after administration, because lispro insulin peaks in 1 to 3 hrs.

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Auscultating the rate and characteristics of the child's heart sounds Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place priority on auscultating the client's heart rate and heart sounds. Rheumatic fever is an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

Avoid eating meat that is not well-done.

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis.Which of the following instructions should the nurse include in the teaching plan?

Avoid foods high in fat. Rationale: The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has an intolerance to fatty foods.

A nurse is caring for a client who is HIV positive and is one day postoperative following an cholecystectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?

Bathing the client after they accidentally had a bowel movement in the bed. Rationale: Standard precautions require personal protective equipment when there is a risk of contact with body fluids. Bathing a client does present a risk for coming into contact with body fluids.

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?Be sure the client remains on bed rest.

Be sure the client remains on bed rest.

A nurse is assessing a female client who is at risk for developing type 2 diabetes mellitus. The nurse should identify that which of the following manifestations increases the client's risk for developing type 2 diabetes?

Blood pressure 138/98 mm Hg Rationale: A female client who has a blood pressure greater than 130 mm Hg systolic and 85 mm Hg diastolic is at risk for type 2 diabetes.

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

Blurred vision, tachycardia, and moist clammy skin

A nurse is providing teaching to a client who has a new diagnosis of testicular cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Close male relatives are at an increased risk of developing testicular cancer and Testicular cancer typically occurs between ages 15 and 35.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3 Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3 Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.C.

A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client to take which of the following supplements while taking this medication?

Calcium and vitamin D Rationale: Long-term use of glucocorticoids, such as prednisone, places the client at risk for osteoporosis.The nurse should instruct the client to take calcium and vitamin D supplements to reduce this risk.

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Candidiasis Rationale: Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults, and clients whose immune systems have been compromised by illness, such as AIDS,or medications.

A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Check the client's voice every 2 hr. Rationale: The nurse should assess the client's voice every 2 hr to monitor for hoarseness, which is a manifestation of laryngeal nerve damage.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP).The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Check the tubing for kinks. Rationale: When providing client care, the nurse should first use the least restrictive intervention;therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?

Check urine specific gravity. Rationale: The nurse should check the client's urine specific gravity to monitor urine concentration in a client who has diabetes insipidus. A client who has diabetes insipidus has a urine specific gravity of less than 1.005.

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

Check your urine for ketones when blood glucose levels are greater than 240 mg/dL. "Rationale: The client should check his urine for ketones when blood glucose levels are greater than 240mg/dL in order to detect DKA. The client should contact the provider if he has moderate or large amounts of ketones in his urine.

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Chvostek's sign Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only)facial muscles, suggesting neuromuscular excitability due to hypocalcemia.

A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions?

Cirrhosis Rationale: The nurse should recognizes this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis.

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Clay-colored stools

A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?

Completing a dressing change Rationale: Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids.

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?

Connective tissue Rationale: SLE originates in the connective tissues of the body and affects all organ systems.

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?

Encourage short periods of ambulation. Rationale: The nurse should encourage a client who has hepatitis B to alternate between activity and rest.

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors?

Dark and foamy Rationale: The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results?

Decreased thyroid-stimulating hormone (TSH) level Rationale: The nurse should expect a TSH level below the expected reference range in a client who has Graves' disease.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Dehydration Rationale: Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine Rationale: Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include?

Do not exercise if ketones are present in your urine. Rationale: The nurse should instruct the client not exercise if ketones are present in her urine because this is an indication of inadequate insulin and increases the risk for hyperglycemia.

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)

Don a mask, gloves, and gown. Restrict visitors who have active infections.

A nurse is teaching a client who has a new diagnosis of gout about managing the disorder. Which of the following instructions should the nurse include in the teaching?

Eat less liver, sardines, and shrimp. Rationale: Gout results from urate crystals in joint spaces. Potential causes include hyperuricemia due to an overproduction of uric acid and a decreased ability of the kidney to excrete excess uric acid.Uric acid is a product of purine metabolism. The client should reduce the amount of liver,sardines, and shrimp in his diet, as these substances are high in purines.

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

Elevated blood urea nitrogen (BUN) Rationale: As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR) Rationale: Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.

A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms? Which of the following interventions should the nurse include in the teaching?

Establish a regular sleep pattern. Rationale: Lack of sleep contributes to exacerbations of fibromyalgia.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Exercise Rationale: Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest.

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain?

Expel the air from the JP bulb after emptying to re-establish suction. Rational: With the drainage and the air removed and the bulb tightly closed, the system works to exert gentle negative pressure, facilitating the removal of accumulated fluid from the surgical area.

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

Facial edema Rationale: Facial edema is an expected finding of myxedema, which is a severe form of hypothyroidism. A client who has myxedema typically experiences non-pitting edema everywhere, especially around the eyes and in the hands and feet.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial rash Rationale: SLE affects the skin. A facial "butterfly" rash that is dry, scaly, red, and raised is a manifestation of SLE.

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

Fasting blood glucose 155 mg/dL Rationale: A fasting blood glucose above 126 mg/dL meets the criteria for a diagnosis of diabetes mellitus.

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestation of RA?

Fatigue Rationale: Fatigue, weakness, and anorexia are early manifestations of RA.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty stools

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis.Which of the following findings should the nurse expect?

Fatty stools Rationale: Chronic cholecystitis occurs following several bouts of acute cholecystitis. The repeated episodes of inflammation result in a fibrotic and contracted gallbladder. Because of inflammation in the gallbladder, bile needed to absorb fat and fat-soluble vitamins is unable to enter the bowel, resulting in steatorrhea (fatty stools).

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?

Finasteride Rationale: Finasteride, a 5-alpha-reductase inhibitor, is used in the treatment of BPH to prevent the conversion of testosterone and to decrease prostate size.

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?

Flu-like symptoms and night sweats Rationale: The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions?

Fungal infection Rationale: The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones Rationale: The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas.

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?

Graham crackers Rationale: After establishing that the client has hypoglycemia, the nurse should give the client about 15 g o fa rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse should recheck the client's blood glucose level in 15 minutes.

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

Ham sandwich Rationale: Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin and are placed on low-sodium diets.

A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice?

Hard palate

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

HbA1c 7% Rationale: An HbA1c level must be above 6.5% to meet the criteria for a diagnosis of diabetes mellitus.

A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?

Heat intolerance Rationale:The client who has an acute overdose of levothyroxine will exhibit heat intolerance, sweating,and hyperthermia. These manifestations are indications of excessive levels of thyroid hormone that could lead to death.

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which ofthe following findings should the nurse expect?

Hyperpigmentation Rationale: Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Hyperpigmentation Rationale: Hyperpigmentation, bruising, and striae or stretch marks, are manifestations of Cushing's syndrome.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Hypoactive bowel sounds

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. The nurse should identify that the client is likely experiencing which of the following conditions?

Hypoglycemia Rationale: Hypoglycemia is a complication of diabetes indicating a blood glucose level less than 70mg/dL. It can occur when excessive insulin or oral hypoglycemic are administered, with excessive physical activity, or when too little food is consumed. The manifestations of hypoglycemia include sweating, tremor, tachycardia, palpitations, headache, fatigue,nervousness, and hunger.

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?

Hypoglycemia Rationale: Manifestations of hypoglycemia include sweating, tachycardia, tremors, palpitations, hunger,and anxiety.

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

I will check my blood glucose every 4 hours when I am sick." Rationale: The client should follow specific guidelines when sick. The nurse should instruct the client to monitor blood glucose every 3 to 4 hr and continue to take insulin or oral antidiabetic agents.The client should consume 4 oz of sugar-free, non caffeinated liquid every 30 min to prevent dehydration and eet carbohydrate needs through soft food if possible. If not, the client should consume liquids equal to usual carbohydrate content. The nurse should also instruct the client to test urine for ketones and report to provider if they are abnormal (the level should be negative to small).

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?

Immunoglobulin E (IgE) Rationale: A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood.Which of the following actions is the nurse's priority?

Increase the client's IV fluid rate. Rationale: When using the urgent vs. non urgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure.

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

Increased serum amylase rational: With acute pancreatitis, serum amylase rises within 24 hr of the start of the clients symptoms.

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

Inject the insulin 15 min before a meal. Rationale: The nurse should administer lispro insulin 15 min before a meal, because lispro insulin is rapid-acting insulin that has an onset within 15 to 30 min. The client may develop hypoglycemia quickly if they do not eat.

A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?

It is primarily transmitted through direct contact with infected body fluids. Rationale:The nurse should include in the teaching that HIV is transmitted through direct contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk and other body fluids.

A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions?

Kaposi's sarcoma Rationale: Kaposi's sarcoma are AIDS-related malignant skin and mucous membrane lesions that are usually purplish-brown, raised, and edematous.

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the late symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of late symptoms?

Kaposi's sarcoma Rationale: The nurse should explain that Kaposi's sarcoma is not an initial symptom of HIV infection, but islinked in category C where the client is to have AIDS.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition?

Knuckle deformity Rationale: ?Joint deformity is a late manifestation of RA.

A nurse is caring for a client who is postoperative following an open cholecystectomy. The bulb becomes dislodged from the patient. Which of the following actions should the nurse take when caring for this client's Jackson-Pratt (JP) drain?

Leave the drain out of the client, and cover the opening with sterile gauze.

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

Lethargy Rationale: The nurse should identify that lethargy is a manifestation of hypothyroidism. A client who has hypothyroidism reports weakness, fatigue, and somnolence.

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

Loss of color discrimination, Coarse facial features, Enlarged distal extremities, and Hepatomegaly

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH?

Lung cancer Rationale: The nurse should ask the client if he has a history of lung cancer because some of the treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This results in the body retaining water and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

Maintain constant observation while the balloons are inflated. Rationale: A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which ofthe following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin Rationale: Metformin interacts with contrast dye and can cause acute kidney damage.

A nurse is teaching a client who has a new prescription for cyclosporine oral solution to treat rheumatoid arthritis.Which of the following information should the nurse include in the teaching?

Mix with chocolate milk Rationale: The client may combine cyclosporine with milk, chocolate milk, or orange juice to make themedication more palatable.

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?

Monitor the client for hypoglycemia. Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should immediately check the client's blood glucose level, expecting it to below because of the excessive dose of insulin. If it is within the expected reference range, the nurse should continue to monitor the client for signs of hypoglycemia.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Nausea and vomiting Rationale: Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.

A nurse is performing a monofilament sensory assessment of a client who has diabetes mellitus. When performing this assessment, for which of the following complications is the nurse monitoring?

Neuropathy Rationale: Neuropathy is a loss of sensation in the feet, which is a complication that occurs as a result of long term hyperglycemia which affects the microvasculature and causes demyelinization of the nerves. Peripheral neuropathy is assessed by lightly touching a monofilament to different areas of the client's feet to assess the client's ability to feel light touching. An inability to feel light touching is indicative of peripheral neuropathy, which places the client at risk for injury and infection.

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?

Obtain a sputum culture. Rationale: The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

Oliguria Rationale: The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr.

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP)gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?

Output of burgundy colored urine Rationale: Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurses priority?

Oxygen saturation

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.

A nurse is teaching a client who has a new diagnosis of hyperparathyroidism. The nurse should include in the teaching that the client is at risk for which of the following complications?

Pathologic fractures Rationale: A client who has hyperparathyroidism is at risk for pathological fractures due to the release of calcium and phosphate into the blood, which reduces bone density and places the client at risk for pathologic fractures.

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

Place a bed cradle on the client's bed. Rationale: A bed cradle can reduce pain for a client who has diabetic neuropathy by preventing sheets from touching hypersensitive skin.

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?

Place the client in a semi-fowler's position postoperatively.

A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Place the client on aspiration precautions. Rationale: The nurse should place the client on aspiration precautions because the client can have decreased mental status and is at risk for laryngeal edema and tongue thickening.

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?

Practice effective hand hygiene. Rationale: Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A.

A nurse enters a client's room to take their vital signs. The nurse finds the client sleeping heavily, with their skin moist and clammy. The nurse cannot wake the client. The nurse take the client's blood sugar twice and the client is hypoglycemic. What will the nurse prepare to do next?

Prepare to give the client Dextrose 50% IV per protocol. Rationale: The client is unconscious so we must give them something via IV. Remember that this client is in the hospital so we have IV access available.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema. Rationale: The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease.Which of the following activities should the nurse include in the teaching?

Press water from a sponge rather than wringing it. Rationale: The nurse should instruct the client to modify fine motor activities, such as wringing out as ponge, by using larger joints or body surfaces, such as the palm of the hand, to substitute for smaller ones.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching?

Prolonged obstruction of the common bile duct is the most common cause of biliary cirrhosis.

A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care?

Provide a high carbohydrate diet. Rationale: A client with hepatitis should have a diet high in carbohydrates due to altered nutrient metabolism.

A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?

Provide a quiet, low-stimulus environment. Rationale: Thyroid crisis can occur in response to a stressor, so the nurse should minimize stressful stimuli in the client's environment.

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?

Quantitative RNA assay Rationale: A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)

Reduce cholesterol and saturated fat intake, Increase physical activity and daily exercise, Enroll in a smoking-cessation program, and Maintain optimal blood pressure to prevent kidney damage.

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?

Reduced joint stress Rationale: Rheumatoid arthritis in an autoimmune disease in which the cartilage and bone of the joints are destroyed resulting in increased pain and limited range of motion. The nurse should instruct the client that rest reduces stress on the joints and can be an effective intervention for relieving pain associated with rheumatoid arthritis.

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Regular insulin Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching?

Rest frequently throughout the day. Rationale: Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands.

A nurse is caring for a client who has a syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?

Restrict fluid intake to 1,000 mL per day. Rationale: Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa.

A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching?

Restrict sodium intake. Rationale: The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from "no-added-salt" to table foods to a restriction of 2 g/day.

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse gets the client's blood sugar reading and itis 42. The client is alert and oriented and says they feel fine. What is the next best action by the nurse?

Retake the client's blood sugar. Rationale: The client appears alert and oriented and is not showing signs of hypoglycemia. It's important that the nurse recheck the blood sugar before treating the client unnecessarily.

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the clients diet?

Roast turkey rational: Roast turkey is a low-fat protein that is an appropriate choice for inclusion in the clients diet. Low-fat food decreases stimulation of the gallbladder, thereby reducing associated symptoms.

A nurse is teaching a client who has gout about medications. The nurse should teach the client to avoid the use of which of the following types of medication?

Salicylates Rationale: Salicylates, such as aspirin, and diuretics can trigger gout attacks.

A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

Semi-Fowler's with neck in a neutral position Rationale: Semi-Fowler's is the most comfortable position for a client who has had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the sutures. A neutral position is essential.

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

Serum creatinine Rationale: A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function.

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Stridor Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45&deg or more, if tolerable, and call for emergency assistance.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis?

Tachycardia Rationale: Tachycardia is a manifestation of diabetes insipidus due to dehydration from fluid loss.

A nurse is teaching a student nurse about systemic lupus erythematosus (SLE). The student nurse recognizes that the following places the client at a higher risk of infection.

Taking steroid medications Rationale: Infection is a major stressor on the body and can trigger an exacerbation of the SLE disease process. In addition, many clients who have SLE take steroid medications that place them at higher risk for infection.

A nurse is reviewing the laboratory results for four clients. The nurse should recognize that which of the following clients has a manifestation of primary hyperparathyroidism?

The client who has an increased magnesium level Rationale: Magnesium level is increased in a client who has primary hyperparathyroidism.

A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?

The client will receive medication to minimize episodes of breakthrough pain. Rationale: The client should receive medication to minimize episodes of breakthrough pain as a goal for the end of life care.

A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client?

The medication should be discontinued 3 months prior to a planned pregnancy Rationale: Methotrexate should be discontinued 3 months prior to planning a pregnancy because of the risk of birth defects.

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

Thyroid stimulating hormone (TSH) Rationale: The nurse should anticipate that TSH will be elevated.

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

Tingling of the extremities Rationale: A serum calcium level of 7.6 mg/dL is below the expected reference range, indicating hypocalcemia. A client who undergoes a total thyroidectomy is at risk for parathyroid injury which can lead to hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysrhythmias.

A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

Tissue damage at the site Rationale: The nurse should expect the manifestations of edema, induration, ischemia, and tissue damage at the site occurring hours to days after exposure. A positive purified protein derivative test for tuberculosis is an example of a type IV hypersensitivity reaction.

A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Transplant rejection Rationale: Transplant rejection is affected by the cellular response, or cell-mediated immunity, of the T-cells.

A nurse is teaching about levothyroxine with a client who has primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

Tremors, nervousness, and insomnia may indicate your dose is too high." Rationale: The nurse should teach that tremors, nervousness, and insomnia may indicate an overdose of the medication and to notify the provider.

A nurse is teaching a client who has chronic tophaceous gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances?

Uric acid Rationale: Hyperuricemia is the underlying cause of gout. Clients who have chronic gout develop tophi.The purpose of allopurinol is to reduce the synthesis of uric acid.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Urine specific gravity 1.002 Rationale: The nurse should expect a client who has diabetes insipidus to have diluted urine with a specific gravity less than 1.005.

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?

Urine specific gravity 1.015 Rationale: A therapeutic effect of the medication would be urine specific gravity within the expected reference range, which is 1.010-1.025.

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP)and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

Use sterile technique when preparing the irrigation solution, Ensure the drainage tubing is patent and without obstruction, and Notify the surgeon if the urine is bright red in appearance or has large clots.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Verify the most recent calcium level. Rationale: A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

Weigh the client daily. Rationale: Addison's disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue,low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client's daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis.

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

Weight gain Rationale: The nurse should expect to find weight gain in clients who have hypothyroidism, even with no change in dietary intake.

A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect?

Weight loss Rationale: Weight loss is an expected finding for a client who has uncontrolled diabetes.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Western blot analysis Rationale: The Western blot analysis is used to confirm seropositivity when the ELISA test has a positive result. ELISA is inexpensive and accurate with few false-positives. Western blot is expensive,so is done only for confirmation.

A nurse is assisting a client who has hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to her diet?

Whole grains Rationale: Constipation is a classic manifestation of hypothyroidism; therefore, this client should increase her fluid and fiber intake. Whole grains provide ample amounts of fiber.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food. Rationale: To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP).When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for?

bleeding Rationale: Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding.In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is an early manifestation of this condition?

low-grade fever Rationale: ?Persistent low-grade fever is an early manifestation of RA.