MSIII_FINAL SI

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side‐lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.

A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side‐lying position so secretions can drain from the mouth keeping the airway patent. B. The nurse should document the duration of the seizure in the client's medical record, but there is another action that the nurse should take first. C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first. D. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first. ATI

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? A. Absence of glucose B. Decreased specific gravity C. Presence of ketones D. Presence of red blood cells

A. Glucose in the urine is indicative of diabetes mellitus. B. CORRECT: The urine of a client who has diabetes insipidus will be dilute with a urine specific gravity of less than 1.005. C. Ketones in the urine is indicative of diabetes mellitus. D. Red blood cells in the urine is indicative of diabetes mellitus. ATI Ch77

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

A. Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored. ATI CH14

A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. lifestyle changes to lower blood glucose. b. using lower doses of insulin. c. self-monitoring of blood glucose. d. effects of oral hypoglycemic medications.

A. The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

B After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed. -See Lewis page 1209-

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? a. Prealbumin level b. Urine ketone level c. Fasting glucose level d. Glycosylated hemoglobin level

D. Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

The nurse is assigned to the care of a 64-year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? a. Assess patient's perception of what it means to have diabetes. b. Ask the patient to write down current knowledge about diabetes. c. Set goals for the patient to actively participate in managing his diabetes. d. Assume responsibility for all of the patient's care to decrease stress level.

a. Assess patient's perception of what it means to have diabetes. In order for teaching to be effective, the first step is to assess the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

a. Bradycardia Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

a. Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? a. Increased triglyceride levels b. Increased high-density lipoproteins (HDL) c. Decreased low-density lipoproteins (LDL) d. Decreased very-low-density lipoproteins (VLDL)

a. Increased triglyceride levels. Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

A nurse in an acute care facility is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse anticipate? (Select all that apply.) A. IV therapy with 0.45% sodium chloride B. Regular insulin C. Hydrocortisone sodium succinate D. Sodium polystyrene sulfonate E. Furosemide

A. 0.45% sodium chloride is hypotonic. Clients who have acute adrenal insufficiency are hyponatremic. The nurse should anticipate a prescription for a solution that contains 0.9% sodium chloride. B. CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Insulin is administered to shift potassium into the cells. C. CORRECT: Hydrocortisone sodium succinate is administered as replacement therapy of both glucocorticoid and mineralocorticoid. D. CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Sodium polystyrene sulfonate is administered because it absorbs potassium. E. CORRECT: Loop and thiazide diuretics promote potassium excretion and are administer to treat hyperkalemia.

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Assist the client to use flash cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.

A. CORRECT: Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. CORRECT: One strategy that can enhance understanding is the use of alternative forms of communication, such as ash cards with pictures or a computer. C. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. D. The nurse should allow the client adequate time to finish sentences and not complete the sentences for him. E. CORRECT: One strategy that can enhance understanding is giving instructions one step at a time. ATI

A nurse is reviewing the health record of a client who has hyperglycemic‐hyperosmolar state (HHS). The nurse should identify that which of the following data confirm this diagnosis? (Select all that apply.) A. Evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years E. No insulin production

A. CORRECT: The client who has type 2 diabetes mellitus and had a myocardial infarction is at risk for developing HHS. This is due to the increased hormone production during illness or stress, which can stimulate the liver to produce glucose and decrease the effects of insulin. B. CORRECT: The client who has type 2 diabetes mellitus can be at risk for developing HHS when the BUN is 35 mg/dL because it is an indication of decreased kidney function and inability of the kidney to filter high levels of blood glucose into the urine. C. CORRECT: A calcium channel blocker is one of several medications that increase the risk for HHS in a client who has type 2 diabetes mellitus. D. CORRECT: The older adult client is at risk for developing type 2 diabetes mellitus and can be unaware of associated manifestations, increasing the risk for HHS. E. The client who has type 2 diabetes mellitus can produce enough insulin to prevent ketoacidosis but not enough to control blood glucose, resulting in HHS.

A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for this client? (Select all that apply.) A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocyte count 35% E. Fasting glucose 145 mg/dL

A. CORRECT: This finding is above the expected reference range. Hypernatremia is an expected finding for clients who have Cushing's disease. B. CORRECT: This finding is below the expected reference range. Hypokalemia is an expected finding for clients who have Cushing's disease. C. CORRECT: This finding is below the expected reference range. Hypocalcemia is an expected finding for clients who have Cushing's disease. D. This finding is within the expected reference range. A decreased lymphocyte count is an expected finding for clients who have Cushing's disease. E. CORRECT: This finding is above the expected reference range. Clients who have Cushing's disease have an elevated fasting blood glucose because the disorder affects glucose metabolism.

A nurse is providing discharge reaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply.) A. Brush your teeth after every meal or snack. B. Avoid bending at the knees. C. Eat a high‐fiber diet. D. Notify the provider of any sweet‐tasting drainage. E. Notify the provider of a diminished sense of smell.

A. The client should avoid brushing his teeth for 2 weeks to allow time for the incision to heal. B. The client should avoid bending at the waist. If bending is necessary, he should bend at the knees. C. CORRECT: To avoid constipation, which contributes to increased intracranial pressure, the client should eat a high‐fiber diet and take docusate. D. CORRECT: Sweet‐tasting fluid is an indication of a cerebrospinal fluid leak. The client should notify the provider. E. Diminished sense of smell is an expected finding after surgery.

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

A. These insulins are not compatible and should not be drawn up in the same syringe. B. These insulins are not compatible and should not be drawn up in the same syringe. C. CORRECT: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe. D. These insulins should be administered at the same time. Regular insulin is short‐acting and should lower the blood glucose level in a short period of time. Insulin glargine is long‐acting and administered once a day.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased serum sodium B. Urine specific gravity 1.001 C. Serum osmolarity 230 mOsm/L D. Polyuria E. Increased thirst

A. CORRECT: A decrease in serum sodium is caused by an increase in the secretion of ADH. B. A urine specific gravity greater than 1.030 is caused by an increase in the secretion of ADH. C. CORRECT: A decrease in serum osmolarity is caused by an increase in the secretion of ADH. D. Reduced urine output is caused by the increase in the secretion of ADH. E. Increased thirst is an expected finding in a client who has diabetes insipidus.

At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A. Weight gain B. Fatigue C. Fragile skin D. Joint pain

A. CORRECT: The greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure; therefore, this is the priority finding. B. Cushing's disease puts the client at risk for fatigue and weight gain; however, another finding is the priority. C. Cushing's disease puts the client at risk for fragile skin and hyperpigmentation; however, another finding is the priority. D. Cushing's disease puts the client at risk for muscle atrophy and pathologic fractures; however, another finding is the priority.

Which statement by a nurse to a newly diagnosed type 2 DM patient would be correct? a. Insulin can't be used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

C. For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Séquard syndrome

b.Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? a. Prevent urinary tract infections. b. Monitor the patient every 15 minutes. c. Encourage him to verbalize his feelings. d. Teach him about using the gastrocolic reflex.

c. Encourage him to verbalize his feelings To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.

The nurse determines that additional instruction is needed when a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) says which of the following? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I will eat foods high in potassium because diuretics cause potassium loss."

A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred. -Lewis page 1193-

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? a. The patient is confused and lethargic. b. The patient reports a recent head injury. c. The patient has a urine output of 400 mL/hr. d. The patient's urine specific gravity is 1.003.

A The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

A nurse is assessing a client who has experienced a left‐hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

A. A client who has experienced a right‐hemispheric stroke will experience difficulty with impulse control. B. A client who has experienced a right‐hemispheric stroke will experience poor judgment. C. CORRECT: A client who experienced a left‐hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who experienced a right‐hemispheric stroke will experience a loss of depth perception. ATI

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the wheelchair on the client's left side.

A. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn his head to the left to visualize the entire field of vision. B. CORRECT: The client is unable to visualize to the left midline of her body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. C. Using the clock method of food placement will be ineffective because only half of the plate can be seen. D. The wheelchair should be placed to the client's right or unaffected side. ATI

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over‐the‐counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed‐toe shoes.

A. A podiatrist should remove calluses or corns. Over‐the‐counter remedies can increase the risk for tissue injury and an infection. B. Applying lotion between the toes increases moisture for growth of micro‐organisms, which can lead to infection. C. CORRECT: Perform nail care after bathing, when toenails are soft and easier to trim. D. CORRECT: Trim toenails straight across to prevent injury to soft tissue of the toes. E. CORRECT: Wear closed‐toe shoes to prevent injury to soft tissue of the toes and feet.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse implement? A. Check blood glucose immediately after breakfast. B. Administer insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

A. Blood glucose should be checked prior to insulin administration to prevent an episode of hypoglycemia. B. CORRECT: Administer insulin aspart when breakfast arrives to avoid a hypoglycemic episode. Insulin aspart is rapid‐acting, and should be administered 5 to 10 min before breakfast. C. Insulin aspart is rapid‐acting and is administered 5 to 10 min before breakfast. Breakfast should be available at the time of the injection. D. Insulin aspart is administered at breakfast time and may be prescribed for administration 2 to 3 times a day.

A nurse is caring for a client who has experienced a right‐hemispheric stroke. Which of the following are expected findings? (Select all that apply.) A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness

A. CORRECT: A client who has experienced a right‐hemispheric stroke will exhibit impulse control difficulty, such as the urgency to use the restroom. B. CORRECT: A client who has experienced a right‐hemispheric stroke will exhibit left‐sided hemiplegia. C. CORRECT: A client who has experienced a right‐hemispheric stroke will experience a loss in depth perception. D. A client who has experienced a left‐hemispheric stroke will experience aphasia. E. CORRECT: A client who has experienced a right‐hemispheric stroke will demonstrate a lack of awareness of surroundings. ATI

A nurse is providing discharge teaching to a client who has experienced diabetic ketoacidosis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. D. Notify the provider when blood glucose is 200 mg/dL. E. Report ketones in the urine after 24 hr of illness.

A. CORRECT: Drinking 2 L fluids daily can prevent dehydration if the client develops diabetic ketoacidosis. B. CORRECT: Blood glucose tends to increase during illness. Blood glucose should be monitored every 4 hr. C. CORRECT: Illness often causes blood glucose to increase. Regular doses of insulin should be administered. D. Notify the provider when blood glucose is greater than 250 mg/dL. E. CORRECT: The provider should be notified if there are ketones in the urine after 24 hr of illness.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. -ATI CH14- E. Hypertension, not hypotension, is a finding associated with increased ICP.

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega‐3 fatty acids in the diet.

A. CORRECT: Healthy nutrition should include decreasing the consumption of meats and processed foods, which can prevent diabetes and hyperlipidemia. B. CORRECT: Healthy nutrition should include lowering LDL by decreasing intake of saturated fats, which can prevent diabetes and hyperlipidemia. C. CORRECT: Healthy nutrition should include increasing dietary fiber to control weight gain and decrease the risk of diabetes and hyperlipidemia. D. The recommended saturated fat intake is no more than 7% of total daily caloric intake. E. CORRECT: Healthy nutrition should include omega‐3 fatty acids for secondary prevention of diabetes and heart disease.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed.

A. CORRECT: Suction equipment should be available in case of choking and aspiration. B. CORRECT: The client should be given liquids that are thicker than water to prevent aspiration. C. CORRECT: Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration. D. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. E. CORRECT: The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing. ATI

A nurse is planning care for a client who has Cushing's disease. The nurse should recognize that clients who have Cushing's disease are at increased risk for which of the following? (Select all that apply.) A. Infection B. Gastric ulcer C. Renal calculi D. Bone fractures E. Dysphagia

A. CORRECT: Suppression of the immune system places the client at risk for infection. B. CORRECT: The overproduction of cortisol inhibits the production of a protective mucus lining in the stomach and causes an increase in the amount of gastric acid. These factors place clients who have Cushing's disease at increased risk for gastric ulcers. C. Clients who have Cushing's disease are not at risk for renal calculi, but they are at risk for neurological and cardiovascular problems. D. CORRECT: Clients who have Cushing's disease are at risk for bone fractures because decreased calcium absorption leads to osteoporosis. E. Clients who have Cushing's disease are not at risk for dysphagia, but they are at risk for other gastrointestinal problems, including anorexia, nausea, vomiting, and abdominal pain.

A nurse is caring for a client who was recently admitted to the emergency department following a head‐on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time. -ATI CH14-

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the oor to prevent falling and injury. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. The nurse should not restrain the client. Restraint can increase the client's risk for injury or more seizure activity. ATI

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.

A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity. D. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure. E. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity. F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity. ATI

A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? (Select all that apply.) A. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL D. Blood urea nitrogen (BUN) 28 mg/dL E. Fasting blood glucose 148 mg/dL

A. CORRECT: This finding is below the expected reference range. In the presence of Addison's disease, insufficient glucose can cause sodium and water excretion. Hyponatremia is an expected finding. B. CORRECT: This finding is above the expected reference range. Hyperkalemia is an expected finding for a client who has Addison's disease. C. CORRECT: This finding is above the expected reference range. Hypercalcemia is an expected finding for a client who has Addison's disease. D. CORRECT: This BUN level is above the expected reference range, which is an expected finding for a client who has Addison's disease due to dehydration. E. This finding is above the expected reference range for a fasting blood glucose level. Hypoglycemia or blood glucose in the normal range is an expected finding for a client who has Addison's disease, so this finding is unexpected.

A nurse is caring for a client who is 6 hr postoperative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? A. RBCs B. Ketones C. Glucose D. Streptococci

A. Cerebrospinal fluid does not contain RBCs unless the client has a cerebral hemorrhage or the procedure was traumatic. B. Cerebrospinal fluid does not contain ketones, although it does contain protein and lactic acid. C. CORRECT: Cerebral spinal fluid contains glucose. The nurse should test nasal drainage for glucose. D. Cerebrospinal fluid does not contain any bacteria unless the client has meningitis or another infection that involves the brain and spinal cord.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)

A. Clopidogrel (Plavix), C. Dipyridamole (Persantine), D. Enteric-coated aspirin (Ecotrin) Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes. Evolve Ch58

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A. "I can drink up to 2 quarts of fluid a day." B. "I will need to use insulin to control my blood glucose levels." C. "I should expect to gain weight during this illness." D. "Muscle weakness is a symptom of diabetes insipidus."

A. Excessive thirst is a manifestation of diabetes insipidus. Consumption of 4 to 30 L/day can be expected, and fluid intake should not be limited. B. Elevated blood glucose levels are a manifestation of diabetes mellitus. C. Weight loss is a manifestation of diabetes insipidus. D. CORRECT: Muscle weakness, weight loss, extreme thirst, headache, constipation, and dizziness are manifestations of dehydration that occurs with diabetes insipidus.

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyperlipidemia C. Alcohol consumption D. Oral contraceptive use

A. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor. Evolve Ch58

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? A. IV dextrose solution B. IV diazepam (Valium) C. IV phenytoin (Dilantin) D. Oral carbamazepine (Tegretol)

A. IV dextrose solution This patient's seizure is caused by low blood glucose, so IV dextrose solution should be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used to treat seizures from other causes such as head trauma, drugs, and infections. Evolve Ch59

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of the patient's airway B. Positioning to promote cerebral perfusion C. Control of fluid and electrolyte imbalances D. Administration of tissue plasminogen activator (tPA)

A. Maintenance of the patient's airway Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke. Evolve Ch58

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth.

A. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place. Evolve Ch58

A nurse is reviewing laboratory reports of a client who has hyperglycemic‐hyperosmolar state (HHS). The nurse should expect which of the following findings? A. Serum pH 7.2 B. Serum osmolarity 350 mOsm/L C. Serum potassium 3.8 mg/dL D. Serum creatinine 0.8 mg/dL

A. Serum pH of 7.2 is an indication of diabetic ketoacidosis and is not an expected finding for HHS. B. CORRECT: A client who has HHS would have a serum osmolarity greater than 320 mOsm/L. C. Potassium 3.8 mEq/L is within the expected reference range. A client who has HHS would initially have a decreased serum potassium due to diuresis. D. Creatinine 0.8 mg/dL is within the expected reference range. A client who has HHS would have a serum creatinine of greater than 1.5 mg/dL, secondary to dehydration.

A nursing is caring for a client who has a closed‐head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

A. Suctioning increases ICP and should be performed only when indicated. B. CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. The nurse should monitor fluid and electrolyte levels closely for the client who has increased ICP. ATI CH14

A nurse is planning to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base her instructions to the client on which of the following? A. The ACTH stimulation test measures the response by the kidneys to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH. C. ACTH is a hormone produced by the pituitary gland. D. The client is instructed to take a dose of ACTH by mouth the evening before the test.

A. The ACTH stimulation test measures the response by the adrenal glands to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels do not rise in response to administration of ACTH. C. CORRECT: Secretion of corticotropin-releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH. D. ACTH is administered IV during the testing process, and plasma cortisol levels are measured 30 min and 1 hr after the injection.

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

A. The Glasgow Coma Scale is important. However, another assessment is the priority. B. Assessment of cranial nerve function is important. However, another assessment is the priority. C. CORRECT: Using the airway, breathing, and circulation (ABC) priority‐setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. Assessment of pupillary response is important. However, another assessment is the priority.

A nurse is planning care for client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan? A. Maintain the client in a low‐Fowler's position. B. Encourage deep breathing and coughing. C. Encourage the client to brush his teeth when awake and alert. D. Observe dressing drainage for the presence of glucose.

A. The client should be placed into a high‐Fowler's position. B. Coughing should be limited in the client who is postoperative, as this increases intracranial pressure and can cause a leak of CSF. C. Oral care for the client who is postoperative following a transsphenoidal hypophysectomy includes oral rinses and flossing. Brushing teeth can cause a leak of CSF and is contraindicated. D. CORRECT: The nurse should monitor the drainage to the mustache dressing and observe for the presence of glucose, which would indicate the presence of CSF. Notify the provider if this occurs.

A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply.) A. Take the medication on an empty stomach. B. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness. D. Do not discontinue the medication suddenly. E. Eat a low‐sodium diet.

A. The client should take hydrocortisone with food to decrease GI distress. B. CORRECT: Physical and emotional stress increase the need for hydrocortisone. The provider may increase the dosage when stress occurs. C. CORRECT: Weakness and dizziness are indications of adrenal insufficiency. The client should report these indications to the provider. D. CORRECT: Rapid discontinuation can result in adverse effects, including acute adrenal insufficiency. If hydrocortisone is to be discontinued, the dose should be tapered. E. Clients who have Addison's disease are expected to have hyponatremia. A low‐sodium diet is not advised.

A nurse is preparing to administer IV fluids to a client who has diabetic ketoacidosis. Which of the following actions should the nurse take? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer an IV infusion of 0.45% sodium chloride. C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when serum glucose is 350 mg/dL.

A. The nurse should administer an IV infusion of regular insulin at 0.1 unit/kg/hr to gradually lower blood glucose to prevent cerebral edema. B. The administration of an IV infusion of 0.45% sodium chloride should follow the isotonic fluid and is used as maintenance fluids. C. CORRECT: The nurse should rapidly administer an IV infusion of 0.9% sodium chloride, an isotonic fluid, as prescribed to maintain blood perfusion to vital organs. D. The nurse should add glucose to the IV infusion when the serum glucose is 250 mg/dL, not 350 mg/dL, to prevent hypoglycemia and minimize cerebral edema.

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." B. "you should avoid the use of CT scans with contrast." C. "you should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."

A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator. B. The nurse should instruct the client to avoid MRIs, which can affect the function of the stimulator. C. CORRECT: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator. ATI

A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform rst? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 4 oz grape juice. D. Report ndings to the provider.

A. The nurse should recheck the blood glucose in 15 min after a rapidly absorbed carbohydrate is ingested; however, another action is the priority. B. The nurse should give the client a carbohydrate and protein food if the next meal is more than 1 hr away after the blood glucose returns to a normal range; however, the nurse should take another action rst. C. CORRECT: The greatest risk to the client is injury from hypoglycemia; therefore, the priority action the nurse should take is to administer a rapidly absorbed carbohydrate, such as grape juice, takes priority when treating the blood glucose of 52 mg/dL. D. The nurse should report the ndings to the provider; however, the nurse should take another action first.

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

A. Weight loss occurs when the cells are unable to use glucose because of insulin deficiency and places the body in a catabolic state. B. CORRECT: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. CORRECT: Abdominal pain is a GI manifestation of increased ketones and acidosis. D. CORRECT: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. E. CORRECT: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones.

How does a nurse determine that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. weight has increased. b. urinary output is increased. c. peripheral edema is decreased. d. urine specific gravity is increased.

B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder. -Lewis page 1194-

A patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease? a. "I double my dose of hydrocortisone on days I go for a run." b. "I had the stomach flu this week, so I didn't take my hydrocortisone." c. "I frequently eat out, and my food has a lot of added salt." d. "I take twice as much hydrocortisone in the morning as I do in the afternoon."

B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease. -Lewis Page 1212-

The patient is brought to the ED following a car accident and is wearing medical identification that says she has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient? a. Low sodium diet b. Increased glucocorticoid replacement c. Suppression of pituitary ACTH synthesis d. Elimination of mineralocorticoid replacement

B Increased glucocorticoid replacement The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may also need a high sodium diet. Suppression of pituitary ACTH synthesis is done for Cushing syndrome. Elimination of mineralocorticoid replacement cannot be done for Addison's disease.

The patient with systemic lupus erythematosus had been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should the nurse expect to include in this patient's plan of care (select all that apply)? a. Obtain weekly weights. b. Limit fluids to 1000 mL per day. c. Monitor for signs of hypernatremia. d. Minimize turning and range of motion. e. Keep the head of the bed at 10 degrees or less elevation.

B and E Limit fluids to 1000 mL per day and keep the head of the bed at 10 degrees or less elevation. The care for the patient with SIADH will include limiting fluids to 1000 mL per day or less to decrease weight, increase osmolality, and improve symptoms; and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. The weights should be done daily along with intake and output. Signs of hyponatremia should be monitored, and frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A 54-year-old patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? a. "With type 2 diabetes, the body of the pancreas becomes inflamed." b. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." c. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." d. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

B. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced, and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the massage of areas where skin breakdown emerges.

B. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged. Evolve Ch58

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage. Evolve Ch58

A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. delay eating the noon meal until after the swimming class. b. check glucose level before, during, and after swimming. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.

B. The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise

Which characteristic of a patient's recent seizure is consistent with a focal seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lip smacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain.

B. The seizure involved lip smacking and repetitive movements. The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity. Evolve Ch59

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for A. an aura or focal seizure. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations.

B. nystagmus or confusion. Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity. Evolve Ch59

Which findings will the nurse expect during the assessment of a patient admitted with a diagnosis of Cushing syndrome? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

C. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities. Evolve Ch58

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C. Slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke. Evolve Ch58

Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance for a female patient with Cushing syndrome and is admitted for adrenalectomy? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

D The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices.

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase. Evolve Ch58

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

D. Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation. Evolve Ch58

The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include? a. Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. b. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. c. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. d. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.

b. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate? a. The patient can expect to experience weight loss resulting from increased diuresis. b. The patient should alternate nostrils during administration to prevent nasal irritation. c. The patient should monitor for symptoms of hypernatremia as a side effect of this drug. d. The patient should report any decrease in urinary elimination to the health care provider.

b. The patient should alternate nostrils during administration to prevent nasal irritation. DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Inhaled DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia. Diuresis will be decreased and is expected, and hypernatremia should not occur.

A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? a. Drink more milk. b. Eat 20-30 g of fiber per day. c. Use oral laxatives every day. d. Drink 1800 to 2800 mL of water or juice. e. Establish bowel evacuation time at bedtime.

b. and d. Eat 20-30 g of fiber per day. Drink 1800 to 2800 mL of water or juice. The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? a. Central apnea b. Hypoventilation c. Kussmaul respirations d. Cheyne-Stokes respirations

c. Kussmaul respirations. In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? a. "I want to be rehabilitated for my daughter's wedding in 2 weeks." b. "Rehabilitation will be more work done by me alone to try to get better." c. "I will be able to do all my normal activities after I go through rehabilitation." d. "With rehabilitation, I will be able to function at my highest level of wellness."

d. "With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? a. Risk for impairment of tissue integrity caused by paralysis b. Altered patterns of urinary elimination caused by tetraplegia c. Altered family and individual coping caused by the extent of trauma d. Ineffective airway clearance caused by high cervical spinal cord injury

d. Ineffective airway clearance caused by high cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.