NUR 334 PrepU

A patient has been diagnosed with a lipoma. The nurse explains to the patient that this tumor is located in the part of the brain known as the:

Corpus Callosum.

A nurse working in the medical intensive care unit has a patient admitted with mitral stenosis. The nurse is precepting a new graduate and explains the pathophysiology of the condition. Which of the following statements made by the new graduate would reflect an appropriate understanding of the disease process? Choose all that apply.

"Increased blood flow in the left atrium causes left atrial hypertrophy." "There is a narrowing between the left atrium and left ventricle."

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?

"Tumor removal will promote comfort"

The nurse is aware that a delayed-type hypersensitivity reaction is an example of an immune response. The T lymphocytes involved in this type of reaction are:

Killer T cells.

A nursing instructor is discussing immunodeficiency disorders with students. The instructor tells the class that immunodeficiency disorders are caused by defects or deficiencies in which of the following? Choose all that apply.

The complement system B and T lymphocytes Phagocytic cells

When caring for a client who's being treated for hyperthyroidism, the nurse should:

balance the client's periods of activity and rest.

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

neurological exam

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient?

0-10 mm Hg

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:

Acute attacks with full recovery or residual deficit upon recovery.

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.

Administration of rifampin (Rifadin) Administration of ciprofloxacin hydrochloride (Cipro) Administration of ceftriaxone sodium (Rocephin)

The client had a triple-lumen central catheter inserted in the right subclavian vein and will now receive total parenteral nutrition (TPN). The nurse includes which of the following in the plan of care? (Select all that apply.)

Auscultate lung sounds Check catheter site q2h Monitor blood glucose level q6h

A client has been battling typical pneumonia for about a month, and currently using a second course of antibiotics. What complications can result from pneumonia? Select all that apply.

CHF Shock Septicemia Reason: Empyema (collection of pus in the pleural cavity), pleurisy (inflammation of the pleura), septicemia (infective microorganisms in the blood), atelectasis, hypotension, etc.

Which of the following are considered late signs of increased intracranial pressure (ICP)? Select all that apply.

Cheyne-Stokes breathing Projectile vomiting Hemiplegia

Which condition may contribute to hyperparathyroidism?

Chronic renal failure

A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which of the following actions? Select all that apply.

Continue HIV medications for 4 weeks postexposure. Initiate postexposure testing after 4 weeks. Finish postexposure testing at 6 months.

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:

Dry and pale white

The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections would demonstrate a good understanding of the information provided in the presentation? Select all that apply.

Egg white omelet with spinach and mushrooms Steamed broccoli and carrots Turkey breast on whole wheat bread Reason: Foods high in fat and those that are smoked or preserved with salt or nitrates are associated with increased cancer risks.

In a client infected with human immunodeficiency virus (HIV), CD4+ levels are measured to determine the:

Extent of immune system damage.

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.

Hemodilution Increased urinary output Sodium deficit

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.

Hypotension Venous pooling Tachypnea Hypothermia

The human body is an amazing mechanism with multiple compensatory mechanisms and built-in protection against invasion. One of these systems is the immune system which is a major factor in the prevention or development of cancer. Which of the following is a weapon is the immune system "arsenal"?

Immune suppression

A client in the intensive care unit (ICU) is experiencing decreased afterload resulting from the use of nitrates for chest pain. What effects on the heart will the client experience? (Select all that apply.)

Increased stroke volume Decreased ventricular work Decreased myocardial oxygen requirements

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.

Increased white blood cells Decreased glucose Increased protein

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply.

Initiating rehabilitation Anticipating needs and complications Making nursing assessments Setting priorities for nursing interventions

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.

Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia

A nurse who provides care in a long-term care facility has observed a sharp decline in an 88-year-old man's level of consciousness and activity over the past 36 hours. The nurse recognizes the high incidence of pneumonia among older adults. How does pneumonia present differently among the elderly than among younger patients?

Older adults often lack a fever when they develop pneumonia.

A patient with acute mitral regurgitation should be assessed for the most common initial symptoms. Select all that apply.

Orthopnea Fatigue Dyspnea Weakness

Nursing care for a client in addisonian crisis should include which intervention?

Placing the client in a private room. Reason: The client in addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids.

A patient is suspected to have an air embolus after being in close proximity to an explosion at a sports arena. What position should the nurse place the patient in to prevent migration of the embolus?

Prone left lateral position. Reason: In the event of an air embolus, the patient should be immediately placed in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber (CDC, 2013).

A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize?

Provide frequent, thorough mouth care.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

Pulmonary Hypertension Reason: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension.

Which of the following is an action of the osmotic diuretic mannitol? Select all that apply.

Reduces cerebral edema Enhances cerebral blood flow Reduces blood viscosity Dehydrates brain tissue

The client is admitted to the intensive care unit following surgery. To monitor for accurate fluid intake and output, the client has an indwelling urinary catheter. To prevent an urinary tract infection (UTI), the nurse includes the following interventions in the care plan. (Select all that apply.)

Remove the urinary catheter w/i 48 hours. Cleanse the catheter with soap and water after each bowel movement. Use a leg strap to anchor the catheter to the leg.

Which of the following are the immediate complications of spinal cord injury?

Respiratory arrest Spinal shock

The nurse assesses the laboratory values for a patient with SIADH. Which of the following are consistent with this diagnosis? Select all that apply.

Serum osmolality of 270 mOsm/kg Urine sodium of 30 mEq/L Urine osmolality of 1,500 mOsm/kg

A patient admitted to the hospital is suspected to have rheumatic endocarditis. What diagnostic test does the nurse anticipate will be ordered?

Throat culture

A nurse is aware that the diagnostic feature of ARDS is sudden:

Unresponsive arterial hypoxemia

Hemodynamic monitoring in critical care includes assessing the effects of preload. The critical care nurse understands that increased preload is associated with which of the following causes? Select all that apply.

Vasoconstriction Increased fluid volume

It is important for a nurse to refer an HIV-positive client to support groups and resources because:

support groups and resources provide information about new HIV drug development and clinical drug trials to clients.

The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?

A wide excision of lump will be performed.

A patient is admitted to the ED for the treatment of a large wound to his right leg. After determining that his injuries did not pose an immediate threat to life, the nurse's next priority in treating the wound would be to:

Inspect the wound to assess the extent of damage to underlying structures.

The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.)

Location Size Consistency Reports of tenderness

Which of the following is a common cancer that metastasizes to the spinal cord? Select all that apply.

Lung Breast Prostate

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lung and Browder method

Which of the following are actions of chemical mediators? Select all that apply.

Minimize blood loss Walling off the pathogen Activating phagocytes Promoting formation of fibrous scar tissue Regeneration of scar tissue

A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea as a result of pulmonary venous hypertension. What valvular disorder would cause pulmonary venous hypertension?

Mitral stenosis

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply.

Monitoring the patient for fluid overload Administration of calcitonin Intravenous isotonic saline solution in large quantities

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

Acute diabetes insipidus is associated with significantly increased mortality. Which of the following clinical manifestations should the nurse be alert to? Select all that apply.

Nocturia Urine specific gravity of 1.003 Large amounts of dilute urine Dry mucous membranes

A patient has been brought to the emergency department with multiple trauma after a motor vehicle accident. After immediate threats to life have been corrected, the nurse and trauma team should:

Perform a rapid physical assessment.

A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

Potato chips and chocolate milk shakes

A patient has been diagnosed with mitral valve prolapse (MVP) following an echocardiogram and will begin treatment imminently. When planning this patient's care, the nurse will prioritize:

Preserving the patient's existing level of function

A nursing student assists a registered nurse to admit a client with a primary immunodeficiency. The nurse explains to the student that primary immunodeficiencies predispose people to three conditions. Which of the following three are those conditions?

Severe infections Autoimmunity Cancer

Which of the following are the first symptoms of cardiac tamponade? Select all that apply.

Shortness of breath Chest tightness Dizziness

A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply.

Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells

You are an oncology nurse and have just begun infusion of a patient's first dose of doxorubicin (Adriamycin) for the treatment of the patient's soft-tissue sarcoma. Shortly after beginning the infusion, the patient complains of pain at the infusion site, which is now swollen and reddened, and the IV pump has alarmed with a report of occlusion. As a result, you suspect extravasation. What action should you prioritize?

Stop the infusion and aspirate from the patient's IV line.

Nursing action for extravasation of a chemotherapeutic agent would include which of the following nursing actions? Select all that apply.

Stop the medication infusion at the first sign of extravasation. Aspirate any residual drug from the IV line. Administer an antidote, if indicated.

A nurse is visiting the home of a client with AIDS who is experiencing HIV encephalopathy. When developing the plan of care for the client and his caregiver, the nurse identifies the nursing diagnosis of disturbed thought processes related to confusion and disorientation secondary to HIV encephalopathy. Which expected outcome would be most appropriate for the nurse to document on the client's plan of care?

The client can state that he is at his home.

A water seal system for chest drainage has been inserted into a patient who suffered chest trauma during a motor vehicle accident. At the beginning of the night shift, the nurse has entered the patient's room to assess the system and the patient's condition. Which of the following assessment findings suggests that the system is operating correctly and the patient is maintaining oxygenation?

The water level in the water seal chamber increases when the patient inhales. Reason: There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Water levels should at no time reach the top of the water seal chamber.

Which of the following are antidepressants used in the treatment of AIDS? Select all that apply.

Tofranil Norpramin Prozac

Excessive levels of which neurotransmitter has been implicated in ALS?

Glutamate

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?

18-36 hours

A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments?

Assessing the patient's blood pressure.

A 46-year-old man has been diagnosed with pericarditis and has begun treatment. When assessing this patient, the nurse should prioritize assessments relevant to what complications of pericarditis? Select all that apply.

Cardiac tamponade Pericardial effusion

A nursing student is recalling and discussing a test question with a fellow student. The question asked the students to identify the five disorders of common, primary immunodeficiencies. The student knows that humoral immunity and T-cell defects are two. Choose the other three from the list below.

Combined B- and T-cell defects Phagocytic disorders Complement production

An asymptomatic patient questions the nurse about mitral regurgitation and inquires about continuing exercises. Which of the following is the most appropriate nursing response?

Continue exercise until mild symptoms develop.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

Empyema

Which of the following provides clues about fluid volume status? Select all that apply.

Hourly urine output Daily weights

A patient has safely given birth to her first child, a healthy baby boy. The obstetrical nurse who provided labor support is aware that the infant possesses natural (innate) immunity that can protect him from many pathogens. Which of the following statements most accurately describes an aspect of natural immunity?

Innate immunity is dependent on the ability of cells to differentiate between "self" and "non-self" cells.

Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply.

Papilledema Seizures Headache Nausea with or without vomiting

A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have?

Passive immunity

A patient is recovering from a burn that she experienced 6 weeks earlier. What is a priority in the rehabilitation and predischarge phase of the burn injury?

Patient and family education.

To establish an airway using the head-tilt-chin-lift maneuver in a patient without a suspected cervical spine injury, the first step would be to:

Place the palm of one hand on the forehead and gently push the head backward.

Hattie Willoughby, a 62-year-old female, is two weeks CABG and is returning to her cardiologist due to new symptoms. She reports heaviness in her chest, and pain between her breasts. She reports that leaning forward decreases the pain. After his thorough examination, the cardiologist admits her to the hospital to rule out pericarditis. Which of the following is not a contributing cause to pericarditis?

Pneumonia

You are giving a report in your pathophysiology class. The subject of your report is cancer cells. In differentiating between benign and malignant cells, what characteristics would you cite? Select all that apply.

Rate of growth Ability to cause death Ability to spread

In the interest of public health, the CDC has developed HIV Transmission Prevention strategies. The strategies address the routes by which HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies? Select all that apply.

Sexual activity Illegal drugs

The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is:

Simple to generalized Seizures.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

Singed nasal hair Hoarseness Facial burns

A patient is brought to the emergency department by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?

Small Bowel

A young adult has just been diagnosed with atonic seizures. The nurse practitioner explains to the patient that this type of seizure is characterized by:

Sudden loss of muscle tone that results in a fall.

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that:

Surgery can improve survival time but the results are not guaranteed. Reason: The overall prognosis for this type of aggressive brain tumor is poor but surgery can improve survival time.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse?

Administer oxygen with a nonrebreather mask.

A 26-year-old woman is thankful to be alive after rear-ending a truck with her car. However, she experienced a sternal fracture from the force of her car's airbag and has been breathing shallowly to avoid exacerbating her pain. The nurse should consequently prioritize assessments related to:

Atelectasis Reason: This breathing pattern has the potential to cause diminished ventilation, atelectasis (collapse of unaerated alveoli), pneumonitis, and hypoxemia.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit

A patient is being seen in the health clinic for possible pneumonia. Which of the following is a sign and symptom that identifies viral pneumonia?

Blood cultures are sterile. Reason: Viral pneumonia differs from bacterial pneumonia in that results of blood cultures are sterile, sputum may be more copious, chills are less common, and pulse and respiratory rates are slow.

A 38-year old female client has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility which cares for children infected with AIDS. Which of the following factors will hold the greatest implications during the client's assessment? Choose all that apply.

Her work environment Her history of immunizations and allergies Her use of other drugs

When malignant cells are killed (tumor lysis syndrome), intracellular contents are released into the bloodstream. This leads to which of the following? Select all that apply.

Hyperkalemia Hyperuricemia Hyperphosphatemia

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?

Immerse the child in a cool bath.

The nurse working in the medical intensive care unit has a patient admitted with mitral stenosis. The nurse knows that the pathophysiology of mitral stenosis is consistent with some of the following. Choose all that apply.

Left atrial hypertrophy

A nurse is preparing a presentation about HIV for a local community group. Which of the following would the nurse include in the presentation about HIV transmission? Select all that apply.

The risk of acquiring HIV through the transfusion of blood products is almost nonexistent. The amount of HIV contained in body fluids on exposure is associated with the risk for infection. HIV can be found in seminal fluid, vaginal secretions, and breast milk. Sharing of infected equipment used to inject drugs increases the risk for infection.

An oropharyngeal airway should be inserted:

Upside down and then rotated 180 degrees.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?

Vision changes

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?

Weakness starting in the muscles supplied by the cranial nerves

The client reports shortness of breath. Respirations are 32 breaths per minute. Oxygen saturation is 85%. The nurse performs the following actions in this order. -Place the face mask on the client. -obtain an order for oxygen. -Change to nasal cannula for meals. -Consult with the rapid response team. -Obtain arterial blood gas with FiO2 at 35%.

1.Consult with the rapid response team 2. Obtain order for oxygen 3. place the face mask on the patient 4. obtain ABG w/ FiO2 at 35% 5. Change to nasal cannula for meals

An older adult patient exhibiting clinical manifestations of a brain tumor is admitted to the hospital for testing. What tumor types does the nurse know are commonly seen in the older adult?

Anaplastic astrocytoma Cerebral metastasis from other sites Glioblastoma NOT medulloblastoma

Corticosteroids are used in the treatment of brain tumors for which of the following clinical manifestations? Select all that apply.

Cerebral edema Headache Altered level of consciousness

The nurse is caring for a client who is receiving mechanical ventilation. The physician is increasing the positive end expiratory pressure from 5 cm H2O to 7 cm H20. What complications from this level may arise? (Select all that apply.)

Alveolar rupture Pneumothorax Decreased CO Reason: Barotrauma can occur at levels of PEEP above 5

After administration of epinephrine for an acute anaphylactic reaction, the nurse expects to administer which of the following drugs to treat severe bronchospasm?

Aminophylline

While reviewing the nursing documentation on a patient on the neurological unit, the nurse notes that the patient complained of a headache several times over the previous shift. How can the nurse differentiate between a headache that is caused by a brain tumor and a headache that is caused by meningitis or encephalitis?

Assess for the presence of a fever.

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply.

Decrease in serum thyroid-stimulating hormone (TSH) Increased T3 Increased T4 Increase in radioactive iodine uptake

A medical patient developed a new onset of shortness of breath with pulse oximetry (POX) ranging between 70% and 75% and a respiratory rate of 30 to 35 breaths per minute. The patient did not respond to oxygen therapy with nasal prongs and was fitted with a partial rebreathing mask by the respiratory therapist. When maintaining this patient's oxygen delivery system, the nurse should:

Ensure that the Reservoir bag remains inflated at all times.

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?

Epidural hematoma

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Flaccid

An older adult patient has experienced a severe exacerbation of chronic obstructive pulmonary disease and requires mechanical ventilation. Which of the following settings will be specified by the primary care provider? Select all that apply.

Fraction of inspired oxygen Respiratory Rate Tidal Volume Positive and expiratory pressure (PEEP)

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

Maxillofacial injury and gurgling respirations. Reason: airway!

A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?

Measuring the urine output every 30 minutes.

When a patient takes vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the patient needs to be informed that he should report which of the following symptoms that would be an expected side-effect of motor neuropathy? Select all that apply.

Muscle weakness Cramps and spasms in the legs Loss of balance and coordination

After burning herself by turning off the cold water of her bath, a 3-year-old girl has been brought to the emergency department (ED) with burns that have been assessed as superficial partial-thickness. The ED nurse should recognize which of the following characteristics of this child's burn?

The child's burn will heal spontaneously in approximately 1 week and is unlikely to scar.

The nurse is caring for a patient in the hospital who is receiving a vitamin D supplement. What does the nurse understand is the importance of supplementation with this vitamin? (Select all that apply.)

Vitamin D deficiency is associated with increased risk of common cancers. Vitamin D deficiency is associated with increased risk of autoimmune disease. Vitamin D deficiency is associated with increased risk of inflammatory disorders.

The client has a heart rate of 38 beats per minute. An external pacemaker is prescribed. The nurse plans to

Place pacer electrodes on the front and back of the client's chest Administer prescribed pain and sedative medication Monitor the function of the pacer in relation to the client's cardiac cycle

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

Diplopia

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

Bradycardia Warm skin Venous pooling in the extremities

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Permanent neurologic dysfunction Impaired cellular activity Death

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with:

Depression

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA). Such damage results from multiple factors. Which of the following is a carcinogen?

Dietary substances Environmental factors Viruses Chemical agents Defective genes Medically prescribed interventions

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP?

Providing anticipatory interventions. Reason: Important nursing measures for prevention of HAP include providing anticipatory interventions and preventive care. This scenario is asking about prevention of HAP, not what to do after it occurs, so emotional support and antibiotics are incorrect. Providing extra nutrition is not a preventive measure for HAP.

A patient has sustained a crush injury to the abdomen due to a construction site accident. The nurse knows that, in conjunction with maintaining the airway, breathing, and circulation, the patient must be observed for indicators of acute:

Renal Failure.

An older adult patient who is postmenopausal informs the nurse that she believes she has developed another urinary tract infection (UTI). The nurse understands that postmenopausal females are at greater risk for UTIs. What risk factors do female patients in this age group have? (Select all that apply.)

Residual urine Urinary incontinence Estrogen deficiency