NP2 Practice Q's

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

partial thickness skin loss of dermis

During physical examination of a client, which finding is characteristic of hypothyroidism?

periorbital edema

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

A low-fiber diet

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client?

A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L)

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

A skin infection of the dermis and underlying hypodermis

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

A white color of the skin, which is insensitive to touch

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding would the nurse interpret as a sign or symptom of portal hypertension?

Abdominal distention

A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse plans to monitor for signs and symptoms of which hormone imbalance?

Antidiuretic hormone (ADH)

A client has a tumor that is interfering with the function of the hypothalamus. The nurse would monitor for signs and symptoms related to which imbalance?

Antidiuretic hormone (ADH) excess or deficit

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for its presence?

Ask the client to extend the arms.

What is the thing we are worried about most with Parkinson's

Aspiration

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect?

Autonomic dysreflexia (hyperreflexia)

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation?

Blurred vision

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding would the nurse expect to note in this client?

Bulging eyeballs

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question?

Clear liquid diet

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin?

Clustered skin vesicles

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP?

Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

Contact the health care provider (HCP). Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention.

A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse would expect an excess of which substance?

Cortisol

The nurse notes that the primary health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse would prepare the client for which diagnostic test to confirm this diagnosis?

Culture of the lesion

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client?

Dry skin

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take?

Elevate the head of the bed.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Elevated hematocrit levels

The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication?

Elevated pulse; shakiness; and cool, clammy skin

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider?

Elevated serum bilirubin level

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate?

Encourage the client to recognize that the body changes need to be dealt with. Submit

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition?

Epidural hematoma

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

Eye medications will need to be administered for life.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis?

Fever and tachycardia

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client?

Foam pad

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan?

Gastrointestinal disturbances

A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the primary health care provider's documentation and expects to note which diagnosis?

HHS

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates medication effectiveness by asking the client whether relief was obtained from which symptom?

Heartburn

Addison's disease is characterized by

High K and low NA

Cushing's is characterized by

High NA and low K

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder?

Hypotension

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client?

Hypotension and fever

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply.

Hypoxia Ischemia Hypotension Increased intracranial pressure (ICP)

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?

Inability to pass flatus

A client is undergoing fluid replacement after being burned on 20% of the body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription?

Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?

Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

The nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated prescription?

Intravenous infusion of normal saline

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint?

It has incompletely dislocated.

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include?

It will identify if there is joint injury and provide a route for surgical repair if indicated.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?

Keep the client on NPO (nothing by mouth) status.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?

Leaving the client in an unchilled area of the room

The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms would the nurse look for?

Lesions with well-defined geometric margins

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The nurse is caring for a client with a small bowel obstruction who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse would anticipate a primary health care provider prescription for which type of suction?

Low and intermittent

The nurse is caring for a client with common bile duct obstruction. The nurse would anticipate that the primary health care provider (PHCP) will prescribe which diet for this client?

Low fat

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

Malaise

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention would the nurse include in the plan of care?

Monitor for neck swelling.

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What would the nurse expect to be prescribed for this client?

NPO (nothing by mouth) status

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they would report which early symptom of compartment syndrome?

Numbness and tingling in the fingers

A client has overactivity of the thyroid gland. The nurse would expect which finding?

Nutritional deficiencies

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which nursing action would best assist the client with these manifestations?

Obtain dark glasses for the client.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which sign(s)/symptom(s) of duodenal ulcer?

Pain relieved by food intake

The nurse is assessing a client with cirrhosis for signs and symptoms of low albumin. Which sign or symptom would the nurse expect to note?

Peripheral edema

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. The nurse plans for which most appropriate intervention?

Petal the cast edges with appropriate material.

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding?

Pink color to the skin flap

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar in the client's room.

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?

Place the client in a sitting position.

The nurse is caring for a client diagnosed with a hiatal hernia. Which priority nursing action would the nurse include in the care plan for this client?

Place the client in semi-Fowler's position

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription would the nurse anticipate?

Placing an eye patch over the client's affected eye

A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder?

Polyuria

A nurse is assessing the glycemic status of a client with diabetes mellitus. Which sign or symptom would indicate that the client is developing hyperglycemia?

Polyuria

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply.

Polyuria and bone pain

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food?

Pork Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse would expect to note which finding on assessment of the client?

Positive Trousseau's sign

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?

Presence of asterixis

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted?

Problem with understanding language

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?

Providing information, giving positive feedback, and encouraging relaxation

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client?

Regular insulin via the intravenous (IV) route

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication would the nurse look for during the client's postprocedure assessment?

Rigid abdomen

The nurse is caring for a client with a peptic ulcer who has just undergone an esophagogastroduodenoscopy (EGD). Which client problem would be the priority?

Risk for choking and aspiration related to a poor gag reflex postprocedure

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of Addisonian crisis. The nurse would assess the client for which manifestation that would be associated with this crisis?

Severe abdominal pain

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose would be taken if which symptom or symptoms develop? Select all that apply.

Shakiness, palpitations, light headed

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

Spasms of the entire body

A client who had a brain attack (stroke) has suffered damage to Broca's area of the brain. Which priority assessment would the nurse perform?

Speech

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program?

Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit a sign of thyroid storm. Which is an indicator of this complication?

Tachycardia

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD?

Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose?

Treat hypocalcemic tetany.

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis?

bradycardia

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome?

"Cushing's syndrome is caused by excessive amounts of cortisol."

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction?

"I need to increase my intake of dietary items that are high in calcium." Submit

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching?

"I plan to have a snack 1 hour before going to bed."

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood?

"I should eat foods that have a lot of potassium in them"

A nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction?

"I will need to take daily medications until my symptoms decrease."

The nurse is caring for a client recently diagnosed with a hiatal hernia, and the client asks the nurse to describe a hiatal hernia. How would the nurse respond?

"It is the herniation of the upper part of the stomach into the esophagus through an opening in your diaphragm."

A client with Cushing's syndrome is anxious and verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement would the nurse plan to make to the client?

"Usually these physical changes slowly improve following treatment."

The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition?

"Are you experiencing pain in your joints?" Rationale: Hyperparathyroidism is associated with over secretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

The nurse is interviewing a client with type 2 diabetes mellitus who is taking a sulfonylurea. Which statement by the client indicates an understanding of this treatment for this disorder?

"The medications I'm taking help release the insulin I already make."

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis?

"This skin infection involves the deep dermis and subcutaneous fat."

A client has undergone a 2-hour oral glucose tolerance test (OGTT). Which of the listed glucose levels is compatible with diabetes mellitus at the conclusion of the test?

160

A client admitted to the medical nursing unit has a diagnosis of gastroesophageal reflux disease (GERD). Metoclopramide has been prescribed 4 times a day. When would the nurse schedule administration of the medication?

30 minutes before meals and at bedtime

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted?

99

Vasopressin therapy is prescribed for a client with a diagnosis of cirrhosis who has bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication?

A cardiac monitor

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which would the nurse expect to note on assessment of the client?

A rounded "moonlike" appearance to the face

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what would the nurse plan to use as the most important item for this maneuver?

Abductor splint

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism?

An elevated TSH level

The nurse is providing instructions to the client who is taking antacid tablets. How would the nurse instruct the client to take this medication?

Tea, beer, chocolate, coffee

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with brain attack (stroke) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

The client is aphasic The client has weakness on the right side of the body The client has weakness on the right side of the face and tongue

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse would suspect dysfunction of which endocrine gland?

Thyroid

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia?

Tingling around the mouth

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention?

To have a window cut in the cast

A client is experiencing the syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in which parts of the nephron?

distal tubule and collecting duct

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

flaccid paralysis

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury?

fracture

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods 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 an intention to increase the intake of which food?

legumes

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

urine output

Peritonitis s/s:

• Rigid board like abdomen