nclex final
453. An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of HIV. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assess the infact for which sign? cough liver failure watery stool nuchal rigidity
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456. A health care provider prescribes lab studies for an infant of a woman positive for HIV. The nurse anticipates that which lab study will be prescribed? chest x-ray western blot CD4+ cell count p24 antigen assay
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70. The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client? 1. Ask the client's spouse to supervise the daily administration of the medications. 2. Visit the client weekly to verify compliance with taking the medication. 3. Notify the physician of the client's noncompliance and request a different prescription. 4. Remind the client that tuberculosis can be fatal if it is not treated promptly.
1. Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment. CN: Saf
59. Which of the following techniques for administering the Mantoux test is correct? 1. Hold the needle and syringe almost parallel to the client's skin. 2. Pinch the skin when inserting the needle. 3. Aspirate before injecting the medication. 4. Massage the site after injecting the medication.
1. The Mantoux test is administered via intradermal injection. The appropriate technique for an intradermal injection includes holding the needle and syringe almost parallel to the client's skin, keeping the skin slightly taut when the needle is inserted, and inserting the needle with the bevel side up. There is no need to aspirate, a technique that assesses for incorrect placement in a blood vessel, when giving an intradermal injection. The injection site is not massaged.
53. A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: 1. Vertigo. 2. Facial paralysis. 3. Impaired vision. 4. Difficulty swallowing.
1. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.
The nurse is reviewing the history and physical and physician prescriptions on the chart of a newly admitted client. The nurse should first: 1. Initiate airborne precautions. 2. Apply oxygen at 2 L per nasal cannula. 3. Collect a sputum sample. 4. Reassess vital signs
1. There is a high risk and potential for tuberculosis, and airborne precautions should be implemented immediately to prevent the spread of infection. After initiating precautions the nurse can start the oxygen, check the vital signs, and collect the sputum specimen.
62. The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) indicate(s) that the client has understood the nurse's instructions? Select all that apply. 1. "I will need to dispose of my old clothing when I return home." 2. "I should always cover my mouth and nose when sneezing." 3. "It is important that I isolate myself from family when possible." 4. "I should use paper tissues to cough in and dispose of them promptly." 5. "I can use regular plates and utensils whenever I eat."
2, 4, 5. When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, and using regular plates and utensils indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to be isolated from family members. CN: Health promotion and maintenance;
458. A 6 year old child with HIV has been admitted to the hospital for pain managment. The child asks the nurse if the pain will ever go away. the nurse should make which best response to the child? the pain will go away if you lie still and let the medicine work try not to think about it. the more you think it hurts, the more it will hurt I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less every time it hurts, press on the call button and I will give you something to make the pain go away
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60. A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client: 1. Lives in a long-term care facility. 2. Has no known risk factors. 3. Is immunocompromised. 4. Works as a health care provider in a hospital.
3. An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (eg, prisons, long-term care facilities, hospitals, homeless shelters, etc.), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (eg, diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.
58. The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as: 1. Negative. 2. Needing to be repeated. 3. Positive. 4. False.
3. The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purified protein derivative (PPD) by measuring the size of the firm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a firm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false
457. The mother with HIV infection brings her 10 month old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. the nurse should make which most appropriate response to the mother? I am so please also that everything has turned out fine because symptoms have no developed, it Is unlikely that your infant will develop HIV infection everything looks great, but be sure to return with your infant next month for the scheduled visit most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old
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68. The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis? 1. Take the medication with antacids. 2. Double the dosage if a drug dose is missed. 3. Increase intake of dairy products. 4. Limit alcohol intake.
4. Isoniazid and rifampin (Rifamate) is a hepatotoxic drug. The client should be warned to limit intake of alcohol during drug therapy. The drug should be taken on an empty stomach. If antacids are needed for gastrointestinal distress, they should be taken 1 hour before or 2 hours after the drug is administered. The client should not double the dose of the drug because of potential toxicity. The client taking the drug should avoid foods that are rich in tyramine, such as cheese and dairy products, or he may develop hypertension.
54. The nurse is reconciling the prescriptions for a client diagnosed recently with pulmonary tuberculosis who is being admitted to the hospital for a total hip replacement (see medication prescription sheet). The client asks if it is necessary to take all of these medications while in the hospital. The nurse should: Request that the health care provider review the prescriptions for a duplication between isoniazid and ethambutol. 2. Inform the client that all drugs will be discontinued until the client can eat solid foods. 3. Ask the pharmacist to check for drug interactions between the rifampin and isoniazid. 4. Tell the client that it is important to continue to take the medications because the combination of drugs prevents bacterial resistance.
4. The nurse should tell the client that it is necessary to take all of these medications because combination drug therapy prevents bacterial resistance; they will be administered throughout the hospitalization to maintain blood levels. The health care provider will review the prescriptions per hospital policy because the client is being admitted to the hospital; there is no duplication between any of the drugs being prescribed for this client. It is not necessary to ask the pharmacist to check for drug interactions as these drugs are commonly used together. CN: Pharmacologic and parenteral therapy; CL: Synthesi
56. What is the rationale that supports multidrug treatment for clients with tuberculosis? 1. Multiple drugs potentiate the drugs' actions. 2. Multiple drugs reduce undesirable drug adverse effects. 3. Multiple drugs allow reduced drug dosages to be given. 4. Multiple drugs reduce development of resistant strains of the bacteria.
4. Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (eg, antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs.
70. A new medication regimen is prescribed for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? 1. At bedtime. 2. All at one time. 3. Two hours before mealtime. 4. At the time scheduled.
4. While the client is hospitalized for adjustment of medication, it is essential that the medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness. For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one time, for optimum effectiveness.
A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score? ______________________ points.
42. 15 points The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.
43. The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."
43. 2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.
44. Which of the following nursing measures is not appropriate when providing oral hygiene for a client who has had a stroke? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
44. 1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.
45. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.
45. 3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
46. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.
46. 3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
47. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response. 3. Bowel sounds. 4. Echocardiogram
47. 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.
49. A client newly diagnosed with tuberculosis (TB) is being admitted with the prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room? 1. A room at the end of the hall for privacy. 2. A private room to implement airborne precautions. 3. A room near the nurses' station to ensure confidentiality. 4. A room with windows to allow sunlight.
49. 1. Implementing airborne precautions for possible TB requires a private room assignment. In addition to isolating the client by using a private room, engineering controls can help prevent the spread of TB; a room at the end of the hall will aid in controlling airflow direction and can prevent contamination of air in adjacent areas. Confidentiality is provided for every client, regardless of the client's room location. Sunlight is not a component of isolation precautions.
49. In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize physical limitations. 4. The client can be expected to regain most functional status.
49. 1. The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.
50. Which of the following symptoms is common in clients with active tuberculosis? 1. Weight loss. 2. Increased appetite. 3. Dyspnea on exertion. 4. Mental status changes.
50. 1. Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis. CN
50. Which of the following techniques is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding the client to move up in bed. 3. Lifting the client when moving the client up in bed. 4. Having the client help lift off the bed using a trapeze.
50. 2. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and the limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.
The nurse is caring for a client who is paraplegic as the result of a stroke. At home, the client uses a wheel chair for mobility and can transfer independently. The client is now being treated with IV antibiotics for a sacral wound via a peripherally inserted central catheter. The client is alert and oriented and has no previous history of falling. Using the Morse Fall Scale (see exhibit), what is this client's total score?
51. 35. This client has a fall risk score of 35 and is at medium fall risk due to the client's secondary diagnosis (15) and IV access (20). Though paraplegic, this does not affect the client's fall risk assessment as the client will either be in bed or in a wheelchair; the client therefore is not assessed points on the fall risk for "ambulatory aid" or "gait."
52. A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for: 1. Decreased serum creatinine. 2. Difficulty swallowing. 3. Hearing loss. 4. IV infiltration. ŷ
52. 3. Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin is given via intramuscular injection.
52. Which of the following is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1. Place the client's feet against a firm footboard. 2. Reposition the client every 2 hours. 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. Massage the client's feet and ankles regularly.
52. 3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range- of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli.
53. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.
53. 1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures
54. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly and slowly. 2. Using a "picture board" for the client to point to pictures. 3. Writing directions so client can read them. 4. Speaking in short sentences.
54. 2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.
55. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan. Check all that apply. 1. Maintaining an upright position while eating. 2. Restricting the diet to liquids until swallowing improves. 3. Introducing foods on the unaffected side of the mouth. 4. Keeping distractions to a minimum. 5. Cutting food into large pieces of finger food
55. 1, 3, 4. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.
55. The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: 1. Dust particles. 2. Droplet nuclei. 3. Water. 4. Eating utensils.
55. 2. Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli. Tuberculosis is not spread by eating utensils, dishes, or other fomites.
56. The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: 1. Have a preference for foods high in salt. 2. Eat food on only half of the plate. 3. Forget the names of foods. 4. Not be able to swallow liquids.
56. 2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
57. The client with tuberculosis is to be discharged home with community health nursing follow- up. Of the following nursing interventions, which should have the highest priority? 1. Offering the client emotional support. 2. Teaching the client about the disease and its treatment. 3. Coordinating various agency services. 4. Assessing the client's environment for sanitation
57. 2. Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment.
57. A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.
57. 4. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.
58. A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable
58. 3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.
59. When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. 1. Present one thought at a time. 2. Avoid writing messages. 3. Speak with normal volume. 4. Make use of gestures. 5. Encourage pointing to the needed object.
59. 1, 3, 4, 5. The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.
60. What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.
60. 3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
61. A health care provider has prescribed carbidopa-levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. 1. Explain that the new prescription for Sinemet will treat the depression. 2. Encourage the client to discuss feelings as the Sinemet is being administered. 3. Contact the health care provider before administering the Sinemet. 4. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. 5. Determine if the client is at risk for suicide.
61. 3, 4, 5. The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients wit chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss feelings is appropriate when the prescription is finalized.
62. Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia
62. 2. The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.
63. The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? 1. Maintaining a balanced nutritional diet. 2. Enhancing the immune system. 3. Maintaining a safe environment. 4. Engaging in diversional activity
63. 3. The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern
64. The nurse observes that a when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? 1. The tremors are probably psychological and can be controlled at will. 2. The tremors sometimes disappear with purposeful and voluntary movements. 3. The tremors disappear when the client's attention is diverted by some activity. 4. There is no explanation for the observation; it is a chance occurrence.
64. 2. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client. CN: Physiological adaptation; CL: Analyze
65. At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. Early in the morning, when the client's energy level is high. 2. To coincide with the peak action of drug therapy. 3. Immediately after a rest period. 4. When family members will be available
65. 2. Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy.
66. Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk? 1. Cool and damp weather. 2. Active exercise and exertion. 3. Physical and emotional stress. 4. Rest and inactivity.
66. 3. Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis. CN: Physiological adaptation; CL: A
66. Which goal is the most realistic for a client diagnosed with Parkinson's disease? 1. To cure the disease. 2. To stop progression of the disease. 3. To begin preparations for terminal care. 4. To maintain optimal body function.
66. 4. Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time.
67. Which of the following goals is collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? 1. To maintain joint flexibility. 2. To build muscle strength. 3. To improve muscle endurance. 4. To reduce ataxia.
67. 1. The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective. CN: Physiological adaptation; CL: Synthesize
67. In which areas of the United States and Canada is the incidence of tuberculosis highest? 1. Rural farming areas. 2. Inner-city areas. 3. Areas where clean water standards are low. 4. Suburban areas with significant industrial pollution.
67. 2. Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence. CN
68. A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy? 1. Mood. 2. Muscle rigidity. 3. Appetite. 4. Alertness
68. 2. Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease. CN: Pharmacological and parenteral therapies; CL: Evaluate
69. A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? 1. Euphoria. 2. Jaundice. 3. Vital sign fluctuation. 4. Signs and symptoms of diabetes.
69. 3. Vital signs should be monitored, especially during periods of adjustment. Changes, such as orthostatic hypotension, cardiac irregularities, palpitations, and light-headedness, should be reported immediately. The client may actually experience suicidal or paranoid ideation instead of euphoria. The nurse should monitor the client for elevated liver enzyme levels, such as lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and alkaline phosphatase, but the client should not be jaundiced. The client should not experience signs and symptoms of diabetes or a low serum glucose level, but the nurse should check the hemoglobin and hematocrit levels.
70. A client with neutropenia has an absolute neutrophil count (ANC) of 900 (0.9 × 10 9 /L). What is the client's risk of infection? 1. Normal risk. 2. Moderate risk. 3. High risk. 4. Extremely high risk
70. 2. A client is at moderate risk when the ANC is less than 1,000 (1 × 10 9 /L). The ANC decreases proportionate to the increased risk for infection. Normal risk for infection is when the ANC is 1,500 (1.5 × 10 9 /L) or greater. High risk for infection is when the ANC is less than 500 (0.5 × 10 9 /L). An ANC of 100 (0.1 × 10 9 /L) or less is life threatening. CN: Physiological adaptation; CL: Analyze
71. Which factor in addition to the degree of neutropenia should the nurse assess in determining the client's risk of infection? 1. Length of time neutropenia has existed. 2. Health status before neutropenia. 3. Body build and weight. 4. Resistance to infection in childhood
71. 1. The one factor that may be more important than the degree of neutropenia in determining the risk for infection is the duration of the neutropenia. CN: Physiological adaptation; CL: Analyze
71. A client with Parkinson's disease needs a long time to complete morning care, but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? 1. Tell the client firmly that he or she needs assistance and help with the morning care. 2. Praise the client for the desire to be independent and give extra time and encouragement. 3. Tell the client that he or she is being unrealistic about the abilities and must accept the fact that he or she needs help. 4. Suggest to the client to at least modify the morning care routine if he or she insists on self- care.
71. 2. Ongoing self-care is a major focus for clients with Parkinson's disease. The client should be given additional time as needed and praised for efforts to remain independent. Firmly telling the client that he or she needs assistance will undermine self-esteem and defeat efforts to be independent. Telling the client that perception of the situation is unrealistic does not foster hope in the ability to perform self-care measures. Suggesting that the client modify the morning routine seems to put the hospital or the nurse's time schedule before the client's needs. This will only decrease the client's self- esteem and the desire to try to continue self-care, which is obviously important to the client.
73. The nurse should teach the client with neutropenia and the family to avoid which of the following? 1. Using suppositories or enemas. 2. Using a high-efficiency particulate air (HEPA) filter mask. 3. Performing perianal care after every bowel movement. 4. Performing oral care after every meal
73. 1. The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices. The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx. CN: Health promotion and maintenance; CL: Synthesize
73. The nurse should conduct a focused assessment with the client with multiple sclerosis for risk of which of the following? Select all that apply. 1. Dehydration. 2. Falls. 3. Seizures. 4. Skin breakdown. 5. Fatigue.
73. 2, 4, 5. The client with multiple sclerosis is at risk for falls due to muscle weakness, skin breakdown due to bowel and bladder incontinence, and fatigue. The client is not at risk for dehydration; seizures are not associated with myelin destruction.
74. The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use intermittent catheterization as needed.
74. 2, 3, 4, 5. Maintaining urinary function in a client with neurogenic bladder dysfunction from MS is an important goal. The client should ideally drink 400 to 500 mL with each meal; 200 mL midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent infection and stone formation. The client may need to catheterize herself to drain residual urine in the bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder training for nighttime continence, the client may restrict fluids for 1 to 2 hours before going to bed. The client should drink at least 2,000 mL every 24 hours.
74. The nurse should remind family members who are visiting a client with granulocytopenia to: 1. Visit only if they do not have a cold. 2. Wash their hands. 3. Leave the children at home. 4. Avoid kissing the client on the lips.
74. 2. Washing hands before, during, and after care has a significant effect in reducing infections. It is advisable to avoid introducing a cold or children's germs and to avoid kissing on the lips, but the primary prevention technique is hand washing. CN: Health promotion and maintenance; CL: Synthesize
75. Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision. 2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors
75. 2. With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.
76. A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite. 3. Relieves muscular spasticity. 4. Reduces the urine bacterial count.
76. 3. Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms common in MS. Drowsiness is an adverse effect, and driving should be avoided if the medication produces a sedative effect. Baclofen does not stimulate the appetite or reduce bacteria in the urine. CN: Pharmacological and parenteral therapies; CL: Evaluate
77. A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures long periods of exacerbation before the illness responds to a particular drug.
77. 2. Evaluating drug effectiveness is difficult because a high percentage of clients with MS exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not what makes evaluation of drug effectiveness difficult.
77. A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure? 1. "You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders." 2. "You will not feel the local anesthetic being applied because it will be sprayed on." 3. "You will feel a pulling type of discomfort for a few seconds." 4. "After the needle is removed, you will feel a bandage being applied around your chest."
77. 3. As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not us
78. Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome? 1. The client maintains bed rest. 2. There is redness and swelling at the aspiration site. 3. The client requests morphine sulfate for pain. 4. There is no bleeding at the aspiration site
78. 4. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed. If the client continues to need the morphine for longer than 24 hours, the nurse should suspect that internal bleeding or increased pressure at the puncture site may be the cause of the pain and should consult the physician. CN: Physiological adaptation; CL: Evaluate
78. When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired
78. 4. Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-to-understand words helps the client to communicate effectively.
79. A client states, "I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now." Which is the nurse's best response? 1. "I'm sure you are frustrated and want to be well now. 2. "Your treatment can be more effective if it is based on more specific information about your disease." 3. "Now, you know the tests are necessary and that you are just upset right now." 4. "I understand how you feel
79. 2. The nurse is an advocate for the client with leukemia who can be empowered with knowledge of the treatment. Immunologic, cytogenic, morphologic, histochemical, and other means are used to identify cell subtypes and stages of leukemia cell development for very specific and optimal treatment. The nurse should not label the client's feeling, such as frustration or emotional; only the client can identify her own feelings. Chastising the client is not helpful. It disavows the client's emotional state and responses to her diagnosis and involved treatment. Unless nurses have had leukemia, they cannot possibly know how the client feels even though they may be trying to offer her empathy. CN: Psychosocial adaptation; CL: Synthesize
79. The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor of the right hand." 2. "Right-hand tremor worsens with purposeful acts." 3. "Needs assistance with dressing and eating due to severe trembling and clumsiness." 4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
79. 4. The nurses' notes should be concise, objective, clearly stated, and relevant. This client trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This activity should be described exactly as it occurs so that others reading the note will have no doubt about the nurse's observation of the client's behavior. Identifying the "intentional" activity of daily living will help the interdisciplinary team individualize the client's plan of care. Clarifying what is meant by "worsening" with a purposeful act will facilitate the interrater reliability of the team. It is better to state what the client did than to give vague nursing orders in the nurses' notes.
80. During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room? 1. A Bible. 2. A picture. 3. A sachet of lavender. 4. A hairbrush.
80. 3. The induction phase of chemotherapy is an aggressive treatment to kill leukemia cells. The client is severely immunocompromised and severely at risk for infection. Flowers, herbs, and plants should be avoided during this time. The client's Bible, pictures, and other personal belongings can be cleaned before being brought into the room to prevent client contact with pathogenic and nonpathogenic organisms. CN: Safety and infection control; CL: Synthesize
80. A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? 1. Eating a diet high in fiber. 2. Setting a regular time for elimination. 3. Using an elevated toilet seat. 4. Limiting fluid intake to 1,000 mL/day.
80. 4. Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position. CN: Physiological adaptation; CL
81. The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements? 1. "I will pace my activities with rest periods." 2. "I can't wait to get home to my cat!" 3. "I will use warm saline gargle instead of brushing my teeth." 4. "I must report a temperature of 100°F (37.7°C)."
81. 2. The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100°F (37.8°C) or higher. CN: Safety and infection control; CL: Evaluate
82. The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: 1. "You will need to accept the necessity for a quiet and inactive lifestyle." 2. "Keep active, use stress reduction strategies, and avoid fatigue." 3. "Follow good health habits to change the course of the disease." 4. "Practice using the mechanical aids that you will need when future disabilities arise."
82. 2. The nurse's most positive approach is to encourage a client with MS to keep active, use stress reduction strategies, and avoid fatigue because it is important to support the immune system while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help minimize complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging.
82. A client with acute myeloid leukemia (AML) reports overhearing one of the other clients say that AML had a very poor prognosis. The client has understood that the client's physician informed the client that his physician told him that he has a good prognosis. Which is the nurse's best response? 1. "You must have misunderstood. Who did you hear that from?" 2. "AML does have a very poor prognosis for poorly differentiated cells." 3. "AML is the most common nonlymphocytic leukemia." 4. "Your doctor stated your prognosis based on the differentiation of your cells."
82. 4. The statement "Your doctor stated your prognosis based on the differentiation of your cells" addresses the client's situation on an individual basis. The nurse is clarifying that clients have different prognoses—even though they may have the same type of leukemia—because of the cell differentiation. Stating that the client misunderstood is inappropriate for an advocate of the client and serves no useful purpose. The other statements are true but do not address this client's individual concern. CN: Psychosocial adaptation; CL: Synthesize
83. Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.
83. 1, 3, 4, 5. A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self- care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities
83. The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent: 1. Cardiac arrhythmias. 2. Liver failure. 3. Renal failure. 4. Hemorrhage.
83. 4. Bleeding and infection are the major complications and causes of death for clients with AML. Bleeding is related to the degree of thrombocytopenia, and infection is related to the degree of neutropenia. Cardiac arrhythmias rarely occur as a result of AML. Liver or renal failure may occur, but neither is a major cause of death in AML. CN: Reduction of risk potential; CL: Synthesize
84. Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? 1. Limit fluid intake to 1,000 mL/day. 2. Insert an indwelling urinary catheter. 3. Establish a regular voiding schedule. 4. Administer prophylactic antibiotics, as prescribed.
84. 3. Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.
84. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: 1. Lymphadenopathy. 2. Hyperplasia of the gum. 3. Bone pain from expansion of marrow. 4. Shortness of breath
84. 4. Although the clinical manifestations of CML vary, clients usually have confusion and shortness of breath related to decreased capillary perfusion to the brain and lungs. Lymphadenopathy is rare in CML. Hyperplasia of the gum and bone pain are clinical manifestations of AML. CN: Reduction of risk potential; CL: Analyze
85. Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is: 1. 4 to 12 years. 2. 20 to 30 years. 3. 40 to 50 years. 4. 60 to 70 years.
85. 1. The peak incidence of ALL is at 4 years of age. ALL is uncommon after 15 years of age. The median age at incidence of CML is 40 to 50 years. The peak incidence of AML occurs at 60 years of age. Two-thirds of cases of chronic lymphocytic leukemia occur in clients older than 60 years of age. CN: Physiological adaptation; CL: Analyze
85. A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? 1. Psychotherapy. 2. Regular exercise. 3. Day care for the granddaughter. 4. Weekly visits by another person with MS.
85. 2. An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients.
86. The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should: 1. Place the client in a private room. 2. Have the client wear a mask. 3. Have staff wear gowns and gloves. 4. Restrict visitors
86. 1. Clients with ALL are at risk for infection due to granulocytopenia. The nurse should place the client in a private room. Strict hand-washing procedures should be enforced and will be the most effective way to prevent infection. It is not necessary to have the client wear a mask. The client is not contagious and the staff does not need to wear gloves. The client can have visitors; however, they should be screened for infection and use hand-washing procedures. CN: Physiological adaptation; CL: Synthesize
87. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: 1. Enlarged, painless lymph nodes. 2. Headache. 3. Hyperplasia of the gums. 4. Unintentional weight loss.
87. 4. Clients with CLL develop unintentional weight loss; fever and drenching night sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy); and susceptibility to viral infections. Enlarged, painless lymph nodes are a clinical manifestation of Hodgkin's lymphoma. A headache would not be one of the early signs and symptoms expected in CLL because CLL does not cross the blood-brain barrier and would not irritate the meninges. Hyperplasia of the gums is a clinical manifestation of AML. CN: Physiological adaptation; CL: Analyze
89. The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement? 1. Ambulating in the hallway. 2. Sitting up in a chair. 3. Lying in bed and taking deep breaths. 4. Using a stationary bicycle in the room.
89. 3. The client with acute leukemia experiences fatigue and deconditioning. Lying in bed and taking deep breaths will not help achieve the goals. The client must get out of bed to increase activity tolerance and improve tidal volume. Ambulating in the hall (using a HEPA filter mask if neutropenic) is a sensible activity and helps improve conditioning. Sitting up in a chair facilitates lung expansion. Using a stationary bicycle in the room allows the client to increase activity as tolerated. CN: Reduction of risk potential; CL: Synthesize
90. The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation? 1. "Combination chemotherapy is used to interrupt cell growth cycle at different points." 2. "Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously." 3. "Combination chemotherapy is used to decrease resistance." 4. "Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent."
90. 2. Combination chemotherapy does not mean two groups of drugs, one to kill the cancer cells and one to treat the adverse effects of the chemotherapy. Combination chemotherapy means that multiple drugs are given to interrupt the cell growth cycle at different points, decrease resistance to a chemotherapy agent, and minimize the toxicity associated with use of a high dose of a single agent (ie, by using multiple agents with different toxicities). CN: Pharmacological and parenteral therapies; CL: Evaluate
91. In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site? 1. Biliary system. 2. Gastrointestinal tract. 3. Brain and meninges. 4. Pulmonary system.
91. 1. The biliary system is not especially prone to hemorrhage. Thrombocytopenia (a low platelet count) leaves the client at risk for a potentially life-threatening spontaneous hemorrhage in the gastrointestinal, respiratory, and intracranial cavities. CN: Physiological adaptation; CL: Analyz
92. The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms: 1. To the client from sources outside the client's environment. 2. From the client to health care personnel, visitors, and other clients. 3. By using special techniques to dispose of contaminated materials. 4. By using special techniques to handle the client's linens and personal items
92. 1. The primary purpose of reverse isolation is to reduce transmission of organisms to the client from sources outside the client's environment. CN: Safety and infection control; CL: Apply
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? "Be sure to tell the health care provider in 2 weeks, as additional screening will be pre- scribed during your second trimester." 1. 2. 3. 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
946. 2Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the prenatal, intrapartal, or postpartum period. HIV transmis- sion can occur during breast-feeding. In the United States and most developed countries, HIV-positive clients are encouraged to bottle-feed their infants (the health care provider's prescrip- tion is always followed). Frequent hand washing is encour- aged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIVinfection, and available financial resources. It is recommended that infants of HIV- positive clients receive antiviral medications for the first 6 weeks of life.Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Recalling the methods of transmission of HIV and that breast-feeding is dis- couraged in the HIV-positive woman will direct you to the cor- rect option.Review: Home care measures for the client with human immu- nodeficiency virus (HIV)Level of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care Environmen
460: the home care nurses provides instructions regarding basic infection control to the parent of an infant with HIV. which statement if made by the parent indicates the need for further instruction? I will clean up any spills from the diaper with diluted alcohol solution I will wash baby bottles, nipples, and pacifiers in the dishwasher I will be sure to prepare foods that are high in calories and high in protein I will be sure to wash my hands carefully before and after caring for my infant
1
69. The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply. 1. Monitor temperature and report elevation. 2. Recognize signs and symptoms of infection. 3. Avoid crowds. 4. Maintain integrity of skin and mucous membranes. 5. Take a baby aspirin each day
1, 2, 3, 4. Nursing care of a client with leukemia includes managing and preventing infection, maintaining integrity of skin and mucous membranes, instituting measures to prevent bleeding, and monitoring for bleeding. Aspirin is an anticoagulant; bleeding tendencies, such as petechiae, ecchymosis, epistaxis, gingival bleeding, and retinal hemorrhages are likely due to thrombocytopenia. CN: Reduction of risk potential; CL: Create
76. A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply. 1. Witness the client signing the consent form. 2. Evaluate that the client understands the procedure. 3. Explain the risks of the procedure to the client. 4. Verify that the client is signing the consent form of his or her own free will. 5. Determine that the client understands postprocedure care
1, 2, 4, 5. The nurse can serve as a witness for consent for procedures. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form, determines that the client is signing the consent of his or her own free will, and determines that the client understands postprocedure care. The nurse's role does not include explaining the risks of the procedure; that responsibility belongs to the person who is to perform the procedure, such as the physician. CN
461. which home care instructions should the nurse provide to the parents of a child with AIDs select all that apply 1) monitor the child's weight 2) frequent hand washing is important 3) the child should avoid exposure to other illnesses 4) the child's immunization schedule will need revision 5) clean up body fluid spills with bleach solution 6) fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special interventions
1,2,3,5
455. The clinical nurse is instructing the parent of a child with HIV regarding immunizations. the nurse should provide which instruction to the parent? the hep B vaccine will not be given to the child the inactivated flu vaccine will be given yearly the varicella vaccine will be given before 6 months of age a western blot test needs to be performed and the results evaluates before immunizations
2
459. the nurse is caring for a 4 year old with HIV. the nurse should expect which statement that is aligned with the psychosocial expectations of this age? being sick is scary I know it hurts to die I know I will be healthy soon i know I am different than other kids
2
64. A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to: 1. Adhere to a low-cholesterol diet. 2. Supplement the diet with pyridoxine (vitamin B6 ). 3. Get extra rest. 4. Avoid excessive sun exposure.
2. INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies
69. A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply. 1. Having eye examinations every 6 months. 2. Maintaining follow-up monitoring of liver enzymes. 3. Decreasing protein intake in the diet. 4. Avoiding alcohol intake. 5. The urine may have an orange color
2, 4, 5. A potential adverse effect of rifampin (Rifadin) is hepatotoxicity. Clients should be instructed to avoid alcohol intake while taking rifampin and keep follow-up appointments for periodic monitoring of liver enzyme levels to detect liver toxicity. Rifampin causes the urine to turn an orange color and the client should understand that this is normal. It is not necessary to restrict protein intake in the diet or have the eyes examined due to rifampin therapy. CN: Pharmacological and parenteral therapies; CL: Create
63. A client has a positive reaction to the Mantoux test. The nurse interprets this reaction to mean that the client has: 1. Active tuberculosis. 2. Had contact with Mycobacterium tuberculosis. 3. Developed a resistance to tubercle bacilli. 4. Developed passive immunity to tuberculosis.
2. A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible.
88. The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every 4 hours while awake the client should use: 1. Lemon-glycerin swabs. 2. A commercial mouthwash. 3. A saline solution. 4. A commercial toothpaste and brush
3. Simple rinses with saline or a baking soda and water solution are effective and moisten the oral mucosa. Commercial mouthwashes and lemon-glycerin swabs contain glycerin and alcohol, which are drying to the mucosa and should be avoided. Brushing after each meal is recommended, but every 4 hours may be too traumatic. During acute leukemia, the neutrophil and platelet counts are often low and a soft-bristle toothbrush, instead of the client's usual brush, should be used to prevent bleeding gums.
65. The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects? 1. Increases the risk of vaginal infection. 2. Has mutagenic effects on ova. 3. Decreases the effectiveness of hormonal contraceptives. 4. Inhibits ovulation.
3. INH interferes with the effectiveness of hormonal contraceptives, and female clients of childbearing age should be counseled to use an alternative form of birth control while taking the drug. INH does not increase the risk of vaginal infection, nor does it affect the ova or ovulation. CN: Pharmacological and parenteral therapies; CL: Apply
454. The nurse provides home care instructions to the parent of a child wiht AIDs. which statement by the parent indicates the need for further teaching? I will wash my hands frequently I will keep my child's immunizations up to date I will avoid direct unprotected contact with my child's body fluids I can send my child to day care if he has a fever, as long as it is a low grade fever
4
75. The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation? 1. Listening to the client's feelings of concern. 2. Completing the client's care in a nonhurried manner. 3. Completing all of the client's care at one time. 4. Instructing the client to dispose of the tissue used after blowing the nose
4 The most common source of infection and microbial colonization in neutropenic clients is their own nonpathogenic normal flora. Attention to personal hygiene, such as oral, pulmonary, urinary, and rectal care, is essential. It is important to acknowledge the client's concerns and fears and to provide organized, nonhurried, caring care, but it is more important to teach the client how to prevent an infection that could be life-threatening. CN: Health promotion and maintenance; CL: Synthesize
61. Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease? 1. 45-year-old mother. 2. 17-year-old daughter. 3. 8-year-old son. 4. 76-year-old grandmother.
4. Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States and Canada include the urban poor, clients with acquired immunodeficiency syndrome, and minority groups. CN: Safety and infection control; CL: Analyze
72. Which of the following is an expected outcome for a client with Parkinson's disease who has a pallidotomy improved? 1. Functional ability. 2. Emotional stress. 3. Alertness. 4. Appetite.
72. 1. The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite.
81. Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will develop: 1. Joint mobility. 2. Muscle strength. 3. Cognition. 4. Mood elevation
81. 3. MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. MS affects speech, coordination, and vision, but not cognition. Care for the client with MS is directed toward maintaining joint mobility, preventing deformities, maintaining muscle strength, rehabilitation, preventing and treating depression, and providing client motivation.
48. A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? suction airway Hyperoxygenate Suction mouth Provide sedation
Sedation Hyperoxygenate Suction airway Suction mouth Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.
