NCLEX liver / cancer / ETOH / Substance abuse from my books/lecture
The nurse observes a client for signs of Korsakoff psychosis. The nurse expects the client to exhibit which finding? 1- Seizures 2- Diplopia 3- Nystagmus 4- Confabulation
Answer: 4
The nurse witnesses a coworker draw up a narcotic medication in a syringe with saline and pocket the vial containing the remaining narcotic. Per the state of Michigan, the nurse knows that she is obligated to report this incident to which of the following? 1- The State Board of Nursing 2- The nurse supervisor on the unit 3- The president of the hospital 4- Contact the local authorities
2- The nurse supervisor on the unit Rationale: Dr. Logghe specifically said this in lecture
Identify the reversible stage of liver disease: 1- cirrhosis 2- fatty liver disease 3- steatohepatitis 4- liver cancer
2- fatty liver disease
Place the progression of liver disease in order: 1- cirrhosis 2- steatohepatitis 3- fatty liver disease 4- liver cancer
3,2,1,4
A patient who is recovering from an alcohol use disorder is being sent home with a prescription for disulfiram (Antabuse). When providing education for this patient, the most important teaching item is what? 1- Disulfiram effects will last two weeks 2- consuming alcohol with this drug will cause harmful effects 3- Take this drug with meals 4- take this drug on an empty stomach
Answer: 2
A young adult client is brought to the ED by a friend. The client is creaming, "I can't stop seeing things. Help me, I'm going crazy." The friend reports the client took some lysergic acid diethylamide earlier in the day. It is most important for the nurse to take which action? 1- Give the client reflective feedback 2- Stay with the client and quietly attempt to talk the client down 3- Set limits on the client's behavior 4- place the client in a well-lighted room close to the nurse's station
Answer: 2
The nurse is caring for a client with cirrhosis understands that which intervention would be included in the clients plan of care? 1-weigh the client weekly 2-elevate the head of the bed 3-encourage increased fluid intake 4-Measure abdominal girth hourly
Answer: 2
The nurse knows that which of the following alcohol-related diseases can be reversed? 1- Korsakoff Syndrome 2- Wernicke's Encephalopathy 3- Cirrhosis 4- Liver cancer
Answer: 2
A nurse is monitoring an 18-year-old who is experiencing heroin withdrawal. What symptoms might the nurse observe? 1-yawning, cramps, and diarrhea 2-nausea and fainting 3-Seizures, tremors, and tachycardia 4-coma and convulsions
Answer: 1
Prolonged alcohol abuse can result in a severe deficiency of what vitamin? 1- thiamine (B1) 2-folate 3-vitamin C 4-niacin (B3)
Answer: 1
The nurse expects which medications to be ordered for a client experiencing Delirium Tremens? 1- phenobarbitol and chlordiazepoxide 2- disulfiram and chlorpromazine 3- disulfiram and barbiturates 4- tricyclics and sedatives
Answer: 1
The nurse is caring for a patient with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about food that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states the intention to increase the intake of what? 1- pork 2- milk 3- chicken 4- broccoli
Answer: 1
The nurse knows that binge drinking is defined by which criteria? 1- Any more than 4-6 drinks in a timeframe over 1-2 days 2- 3 drinks on Sunday during a football game 3- 10 drinks spread out throughout the week 4- Reserving alcoholic drinks for special occasions
Answer: 1 Rationale: Literally quoted from Logghe's lecture
The nurse determines that the spouse of an alcoholic client is benefiting from attending an alcoholic anonymous group if the nurse hears the spouse make which statement? 1-I no longer feel that I deserve the beatings my partner inflicts on me 2- my attendance at the meetings has help me to see that I provoke my partners violence 3-I enjoy attending the meetings because they get me out of the house and away from my partner 4-I can tolerate my partners destructive behaviors now that I know they are common among alcoholics
Answer: 1 Rationale: alcohol anonymous support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for their own behavior and cannot be allowed to blame the family members for loss of control.
The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 1- facial edema in the morning 2- weight loss of 20lb (9kg) in one month 3- serum calcium level of 12 mg/dL 4- serum sodium level of 136 mg/dL 5- serum potassium level of 3.4 mg/dL 6- numbness and tingling of the lower extremities
Answer: 1,3,6 Rationale: Oncological emergencies include sepsis, DIC, SIADH, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 36 mg/dL is a normal level.
A hospitalized client with a history of alcohol use disorder tells the nurse: " I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in one hour. After the nurse discusses the clients concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take? 1-call the Nursing supervisor 2-call security to block all exit areas 3-restrain the client until the primary healthcare provider can be reached 4-tell the client that the client cannot return to this hospital again if the client leaves now
Answer: 1 Rationale: most healthcare facilities have documents that the client is asked to sign relating to the clients responsibilities when the client leaves against medical advice. The client would be asked to wait to speak to the PHCP before leaving and to signed the AMA document before leaving. If the client refuses to do so, the nurse cannot hold the client against the clients well. Therefore, in this situation, the nurse would call the nursing supervisor. The nurse can be charged with false imprisonment if the clients are made to believe that they cannot leave the hospital. Restraining the client in calling security to block exits constitute false imprisonment. All clients have a right to healthcare and cannot be told otherwise
The nurse caring for a patient with liver cirrhosis knows the patient is at risk for developing esophageal varices. If the varices rupture, it is a medical emergency and is very difficult to treat. The nurse knows that the best way to prevent esophageal varices from rupturing include which of the following? 1- Maintaining fluid volume balance 2- Keeping the patient on bed rest 3- Applying consistent pressure around the esophagus 4- Keep the patient NPO
Answer: 1 Rationale: pulled from Logghe's lecture. She said that when fluid volume overload from ascites and portal HTN is sustained, the blood vessels in the esophagus dilate and are at risk of rupturing. The best way to prevent varices from rupturing is to maintain fluid balance so there is not an increase in vascular resistance in the esophageal vessels.
The nurse caring for an end-stage liver patient is doing her morning assessment and notes an early sign of spinal cord compression. Which of the following is the earliest sign of spinal cord compression? 1- back pain 2- muscle weakness 3- numbness in the lower extremities 4-loss of bladder function
Answer: 1 Rationale: spinal cord compression causes back pain before neurological deficits occur. Muscle weakness, numbness, and loss of function are all neurological changes that may occur in the later stages of spinal cord compression
The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory values will the nurse expect to be abnormal? Select all that apply. 1- prothrombin time 2- serum bilirubin 3- albumin 4- aspartate aminotransferase (AST) 5- lactate dehydrogenase (LDH) 6- acid phosphatase
Answer: 1,2,3,4,5
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1- monitor vital signs 2- provide a safe environment 3- address hallucinations therapeutically 4- provide stimulation in the environment 5- provide reality orientation as appropriate 6- maintain NPO status
Answer: 1,2,3,5 Rationale: when the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse should monitor the vital signs closely and report abnormal findings. The nurse would provide a low stimulation environment to maintain the client in as calm of a state as possible. The nurse would re-orient the client to reality frequently and would address hallucinations therapeutically. Additional nutritional and fluid intake needs to be maintained
Which teaching will the nurse include when educating a client who is scheduled to have an esophagogastroduodenoscopy (EGD)? Select all that apply. 1- anesthesia will be used for sedation 2- the procedure takes about 20-30 minutes to complete 3- informed consent will be needed prior to the procedure 4- A separate test will be required to obtain any needed biopsies 5- you will need to refrain from eating for at least 6 to 8 hours before the EGD
Answer: 1,2,4,5
The nurse is caring for a chemically dependent client who has the potential to experience violent episodes. The nurse would implement which interventions? Select all that apply 1-speak slowly to the client 2-move slowly when approaching the client 3- bargaining with the client to prevent violent episodes 4- projecting an attitude of calmness when caring for the client 5- encouraging the client to talk out feelings rather than act on them
Answer: 1,2,4,5 Rationale: dr Logghe quiz
The post surgical client with a heavy history of alcohol is at risk for delirium tremens. The nurse should monitor the client carefully for the development of which signs and symptoms of delirium tremens? Select all that apply 1-fever 2-insomnia 3-bradycardia 4-disorientation 5-fine hand tremors 6-hypertension
Answer: 1,2,4,5,6
Which daily behavior of a client with G.I. problems requires further nursing assessment? Select all that apply. 1- smokes a pack of cigarettes 2- uses fleet enemas to assist with bowel movements 3- practices intentional relaxation 4- eats multiple servings of fruit 5- takes 325 mg of aspirin at night for arthritic pain 6- exercises for 30 minutes three times weekly 7- travels extensively across the world
Answer: 1,2,5,7
The nurse is caring for a client in end-stage liver failure. Which interventions should be implemented when observing for hepatic and cephalopathy? Select all that apply. 1- assess the neurological status as prescribed 2- monitor clients hemoglobin and hematocrit 3- Monitor the clients serum ammonia level 4- Monitor the client electrolyte values daily 5- prepare to insert an esophageal balloon tamponade tube 6- make sure the clients fingernails are short
Answer: 1,3
The nurse is caring for a client with end stage liver failure. Which interventions should be implemented when observing for hepatic and cephalopathy? Select all that apply 1-assess the clients neurologic status as prescribed 2-Monitor the clients hemoglobin and hematocrit levels 3-Monitor the clients ammonia level 4-Monitor the client electrolytes daily 5-make sure the clients fingernails are short
Answer: 1,3
A client has been receiving the same dose of an intravenous opioid for two days to manage post surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse expect? 1-there is likely a history of addiction 2-tolerance to the opioid is developing 3-physical dependence is developing 4-The client is opioid naïve
Answer: 2
The nurse prepares to lead a group session for clients who have a dependence on alcohol. The nurse knows that an alcoholic client drinks because of which reason? 1- the alcoholic enjoys being intoxicated 2- the alcoholic uses alcohol to escape from problems 3- the alcoholic has a greater alcohol tolerance than most people 4- the alcoholic performs more efficiently when drinking
Answer: 2
Which symptom of liver disease does the nurse expect to see in a client with a diagnosis of Laennec cirrhosis? 1- cloudy urine 2- dark urine 3- orange-colored stool 4- tarry stool
Answer: 2
Which of the following symptoms is most worrisome in a patient undergoing alcohol withdrawal? 1- bradycardia 2- delirium tremens 3-tachycardia 4-agitation
Answer: 2 DT can be fatal if left untreated
A patient tells the nurse that they consume 6 beers a week. This statement should prompt the nurse to further assess what? 1- what flavor of beer is it? 2- How many ounces are in each beer? 3- what city did you buy the beer in? 4- Do you drink alone of with your spouse?
Answer: 2 Rationale: 6 beers could mean 6 12oz cans or 6 tall boys. Need specification first. Dr. Logghe said this in lecture.
The spouse of a client admitted to the mental health unit for alcohol with drawl says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse? 1-why don't you tell your spouse about this? 2-what do you find difficult about the situation? 3-this is not the best time to make that decision 4-I agree with you. You should get out of the situation
Answer: 2 Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse would not agree with the client, and the nurse would not request that the client provide explanations.
A client diagnosed with viral hepatitis is complaining of no appetite and losing their taste for food. What instruction would the nurse give the client to provide adequate nutrition? 1- select foods high in fat 2-increase intake of fluids, including juices 3- eat a good supper, when anorexia is less severe 4- eat less often, preferably only three large meals daily
Answer: 2 Rationale: although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low fat diet, as that may be tolerated poorly because of the decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. In adequate fluid intake of 2500 to 3000 mL a day that includes nutritional juices is also important
The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction with the nurse tell the client? 1- administer the iron at meal times 2- administer the iron through a straw 3- mix the iron with cereal to administer 4- Add the iron to apple juice for easy administration
Answer: 2 Rationale: an oral iron supplement needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. Clients need to be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with liquids, cereals, or other food items.
A client with a history of heavy alcohol use is brought to an emergency department by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? 1-tactile hallucinations 2-blood pressure of 180/100 3-mood rating of 2/10 on numeric scale 4-dehydration
Answer: 2 Rationale: the nurse should recognize the high blood pressure is a symptom of alcohol withdrawal and should be promptly reported. Complications associated with withdrawal may progress to delirium tremens and seizure activity. Tactile hallucinations are also a symptom of withdrawal, however a critical blood pressure is more serious than hallucinations
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care? 1- ask the client why they started taking illegal drugs 2- ask the client about the amount of drug use and it's effect 3- ask the client how long they thought that they could take the drugs without someone finding out 4- not ask any questions for fear that the client is in denial and will throw the nurse out of the home
Answer: 2 Rationale: whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being non-judge mental and direct
The state guidelines for an Alternative Disciplinary Program (ADP) for a healthcare provider states they must meet which of the following conditions? Select all that apply. 1- Must get drug tested daily 2- Cannot work the night shift 3- Cannot work in a post-surgical unit 4- Must write an apology letter to their direct supervisor 5- Cannot work more than 8 hours in a day
Answer: 2,3,5 Rationale: pulled from Logghe's lecture
The nurse monitors a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? Select all that apply 1- lethargy 2- diaphoresis 3- tachycardia 4- hypertension 5- abdominal cramps
Answer: 2,5 Rationale: Dr Logghe quiz
A liver scan is prescribed for a client prior to surgery. Which description best describes this procedure? 1- The client will ingest a small amount of radioactive material and venipuncture will be performed to monitor blood levels 2- The client will stand in front of a large machine that takes x-ray pictures of the liver 3- the client will be asked to lie still for a while while a scanning probe is passed back and forth over the body 4- the client's skin will be lubricated with oil and ultrasound pictures will be taken
Answer: 3
A patient who initially came into the ER with intoxication becomes verbally violent and demands to go home. Which statement by the nurse is best? 1- You cannot leave because you are under the influence of alcohol 2- you can leave once we get you sobered up 3- If you wish to leave now, you will need to sign these AMA papers 4- You cannot receive future treatment if you leave now
Answer: 3
Alcohol abuseinduced Thiamine deficiency can cause which of the following? 1-Wolf Hirschhorn syndrome 2-agnosia 3-Wernicke Korsakoff syndrome 4-Lewy body dementia
Answer: 3
On the first day of a client's alcohol detoxification, which nursing intervention should take priority? 1-. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. 2- Educate the client about the biopsychosocial consequences of alcohol abuse. 3- Administer ordered benzodiazepines in a dosage according to protocol. 4- Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
Answer: 3
The nurse is caring for a client with benzodiazepine withdrawal. The nurse would ask the client about abruptly discontinuing which medication? 1-prednisone 2-sertraline 3-diazepam 4-fluoxetine
Answer: 3
The nurse provides care for the client with a history of substance abuse. It is most important for the nurse to select which approach? 1- structures but permissive setting 2- an environment that increases reality testing 3- a structured, nonpermissive setting 4- an environment that decreases stimuli and redirects behavior
Answer: 3
The nurse reviews the records of a client diagnosed with Laennec cirrhosis. The nurse expects to find which lab value? 1- Serum albumin 4.0 2- serum aspartate aminotransferase (AST) 38 3- Serum alanine aminotransaminase (ALT) 600 4- Serum lactate dehydrogenase (LDH) 150
Answer: 3
The nurse would plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1- restrict all visitors 2- restrict fluid intake 3- teach the client and family about the need for hand hygiene 4- insert an indwelling urinary catheter to prevent skin breakdown
Answer: 3
When intervening with a violent client, the nurse takes which action? 1- tells the client that the client has no control over behavior 2- points out that the client is making others anxious 3- Identifies the nurse to the client and remains calm 4- Touches the client gently to offer reassurance
Answer: 3
Which statement made by the alcoholic client to the nurse indicates the client has an accurate understanding of the problem? 1- "when I can learn to stop after one drink, I will have my problems beat" 2- "when my family and work problems go away I wont need alcohol anymore" 3- "I cant seem to cope with my problems without drinking" 4- "in my business, most people work hard and drink too much"
Answer: 3
The nurse observes a cirrhosis patient profusely vomiting blood from a rupture of esophageal varices. The nurse knows that the interventions applied to this patient are based on which priority problem? 1- Aspiration 2- Nutritional deficit- Less than body requirements 3- Hypovolemic shock 4- Altered body image
Answer: 3 Rationale: Dr. Logghe said hypovolemic shock is of greater concern. They most likely won't aspirate because they don't have time to swallow. She specifically said this in lecture.
The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1- cyanosis 2- arm edema 3- periorbital edema 4- mental status changes
Answer: 3 Rationale: early signs and symptoms of superior vena cava syndrome generally occur in the morning and include edema of the face, especially around the eyes, and the client complains of tightness of a shirt or blouse collar. As the compression worsens the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.
The nurse preparing to administer lactulose for a cirrhosis patient with elevated ammonia knows that lactulose works in the digestive system by: 1- stimulating motility of the large intestine 2- inhibit the absorption of water so fecal mass remains large and soft 3- attract water into the large intestine to produce bulk and stimulate peristalsis 4- dilate the intestinal blood vessels to force bowel movement
Answer: 3 Rationale: lactulose is an osmotic laxative that works by attracting water into the large intestine to produce bulk and stimulate peristalsis. Option 1 describes stimulant laxatives. Option 2 describes emollient laxatives. Option 4 is an incorrect selection
The nurse has taught the client about their upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1- I know I must sign the consent form 2- I hope the throat spray keeps me from gagging 3- i'm glad I don't have to lie still for this procedure 4- i'm glad some intravenous medication will be given to relax me
Answer: 3 Rationale: the client does have to lie still for the ERCP, which takes about one hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed
A client who is admitted to the nursing unit following a fall from a second story porch has a history of heroin addiction. The nurse should monitor the client closely for which signs and symptoms of heroin withdrawal? Select all that apply 1-constipation 2-staggering gait 3-goosebumps 4-inability to sleep
Answer: 3,4 Rationale: thermal regulation and circadian rhythm is disrupted
The nurse is reviewing the record of a client diagnosed with cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for its presence? 1- dorsiflex clients foot 2- measure abdominal girth 3- ask the client to extend arms 4- instruct the client to lean forward
Answer: 3- ask the client to extend arms. Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.
The nurse is reviewing the laboratory results for client with cirrhosis and notes that the ammonia level is 85 µg per deciliter. Which dietary selection does the nurse suggest to the client? 1- roast pork 2- cheese omelet 3- pasta with sauce 4- tuna fish sandwich
Answer: 3- pasta with sauce Rationale: serum ammonia level assesses the ability of the liver to dominate protein byproducts. The normal reference interval is between 10 and 80 µg/dL. Most of the ammonia in the body is found in the G.I. tract. Protein in the diet is transported to the liver by the portal vein. The liver breaks down proteins which results in the formation of ammonia. Foods high in protein would be avoided since the clients ammonia level is elevated above the normal range.
The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy . Which assessment findings should the nurse report to the primary healthcare provider? 1- fatigue 2- difficulty sleeping 3- seizure 4- disorientation
Answer: 3- seizure
A client is dealing with alcoholism and liver disease. The nurse recognizes that the resident is coping with many losses. Which intervention is best to address the client psychosocial needs? 1-provide total care for the client 2-medicate the patient for pain every four hours as prescribed 3-mandate participation and social activities daily as part of the clients plan of care 4-visit daily to allow the client to verbalize feelings
Answer: 4
Folate and thiamine support measures are prescribed for clients who have been abusing alcohol to prevent or decrease which complication? 1-cirrhosis 2-liver enlargement 3-esophageal varices 4- Wernicke Korsakoff syndrome
Answer: 4
Following a liver biopsy, the nurse would assist the client into which position? 1-left side lying with right arm elevated 2-right side lying with left arm elevated 3-left side lying with pillow or towel under puncture site 4-right side lying with pillow or towel under puncture site
Answer: 4
Nursing care for the client with substance abuse is based on which principle? 1- the client has difficulty making decisions 2- the client expects too much of themself 3- the client attempts to appease others at all cost 4- the client has limited ability to tolerate anxiety
Answer: 4
The nurse provides care for a client diagnosed with alcoholic cirrhosis. The client is at high risk to develop which complication? 1- Hepatitis B 2- Pancreatic Cancer 3- Weight Gain 4- Epistaxis
Answer: 4
To prepare a client for a paracentesis, it is essential for the nurse to take which action? 1- Administer a cleansing enema 2- pre-medicate the client with a narcotic analgesic 3- restrict the clients fluid intake 4- instruct the client to empty the bladder
Answer: 4
Which client statement indicates a knowledge deficit related to substance abuse? 1- "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2- "Tolerance to heroin develops quickly." 3- "Flashbacks from LSD use may reoccur spontaneously." 4- "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."
Answer: 4
Which term should a nurse use to describe the administration of a central nervous system depressant during alcohol withdrawal? 1-antagonist therapy 2-deterrent therapy 3-codependency therapy 4-substitution therapy
Answer: 4 Rationale: A CNS depressant such as Ativan is used during alcohol withdrawal as a substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system
How often is a drug test initially performed in an Alternative disciplinary program? 1- Every 5-7 days 2- Bi-weekly 3- Every 3-4 weeks 4- Every 6-12 weeks
Answer: 4 Rationale: Dr. Logghe said so in lecture
Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1- elevated hemoglobin level 2- decreased reticulocyte count 3- elevated red blood cell count 4- Red blood cells that are microcytic and hypochromic
Answer: 4 Rationale: an iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency? 1- headache 2- dysphagia 3- constipation 4- Electrocardiographic changes
Answer: 4 Rationale: hypercalcemia is a manifestation of bone metastasis in late stage cancer. Headache and dysphasia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? 1-hypotension, ataxia, hunger 2- stupor, lethargy, muscular rigidity 3- hypotension, coarse hand tremors, lethargy 4- hypertension, change in level of consciousness, hallucinations
Answer: 4 Rationale: symptoms associated with alcohol withdrawal delirium typically include hypertension, tachycardia, nausea and vomiting, tremors, sweating, agitation, tactile disturbances, hallucinations like audio or visual disturbances, headache, and disorientation
A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place highest priority on which item as a part of the clients care plan? 1- monitoring temperature 2- monitoring complaints of heartburn 3- giving warm gargles for sore throat 4- assessing for the return of the gag reflex
Answer: 4 Rationale: the nurse place is highest priority on assessing for the return of the gag reflex. This assessment address is the clients airway. The nurse also monitors the clients vital signs in for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the clients airway is the priority
The AUDIT screening tool classifies 1 drink to be equivalent to: 12oz of beer, 5oz of wine, or 1.5oz of liquor. You are assessing a patient for the number of drinks they have a week and the patient states, "I only have 2 cocktails during the weekend." Upon further questioning, the patient reveals that each cocktail contains 4 shots (6oz) of whiskey. As the nurse, you know that this is equivalent to how many drinks?
Answer: 8 Drinks Rationale: 1.5oz are in 1 shot. 1 shot = 1 drink. Each drink contains 4 shots, so 4x2 is 8 drinks for the two cocktails the patient describes
True or False: Alternative Disciplinary Programs (ADP's) are a mandatory program for healthcare providers
Answer: False. Rationale: ADP's are voluntary for healthcare providers. If they choose NOT to enter into an ADP the hospital can prosecute the healthcare provider under criminal law. (From Logghe's lecture)
When performing a CIWA-Ar evaluation on a patient, the nurse knows that she must assess anxiety by asking which of the following? 1- do you feel anxious? 2- Tell me about your feelings related to your withdrawal 3- Do you feel nervous? 4- You look uncomfortable, as if you are anxious at the moment
Answer; 3 Rationale: CIWA requires straightforward answers, not open ended questions. Straight up asking if they're anxious can make a patient feel defensive, as if they have a diagnosed anxiety disorder. Feeling nervous is a more relatable term for patients. Straight from Dr. Logghe.
CAGE questionaire categories?
Have you ever felt you should cut down on your drinking Have people annoyed you by criticizing your drinking Have you ever felt guilty about your drinking Have you ever had an eye-opener to study nerves in the morning or to cure a hangover
Identify the CIWA-Ar symptomology category for withdrawal (10 sections)
Nausea or vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache Orientation
The nurse is reviewing the medication orders for a patient with a UTI who is also going through opioid withdrawal and sees methadone is ordered. The nurse knows to question the physician if which drug is ordered in addition to methadone? 1- Naltrexone 2- sulfamethoxazole 3- 0.9% normal saline 4- ciprofloxacin
answer: 1 CANNOT give naltrexone in combination with methadone. Will cause seizures.
The nurse in the ER needs a quick and easy screening method for a patient suspected of alcohol abuse. She does not have a lot of time at the moment to perform a thorough assessment, but would still like to begin the process. In this instance, simple 'yes or no' answers would suffice. Which tool would the nurse be most inclined to use? 1- AUDIT 2- CIWA 3- CAGE 4- PEST
answer: 3- CAGE
