NURSE LAB 3
A client with hypertension asks the nurse which factors can cause blood pressure to drop to normal levels? A. Kidneys' excretion to sodium only. B. Kidneys' retention of sodium and water. C. Kidneys' excretion of sodium and water. D. Kidneys' retention of sodium and excretion of water.
The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic blood pressure by regulating blood volume. Option A: As the kidneys excrete sodium, water also goes along with it. Option B: Sodium or water retention would only further increase blood pressure. Option D: Sodium and water travel together across the membrane in the kidneys; one can't travel without the other.
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it? A. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." B. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." C. "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." D. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
Correct Answer: A. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Option B: Drinking a glass of non-diet soda would be appropriate for hypoglycemia. Option C: A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. Option D: A high carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
Johnny, a firefighter, was involved in extinguishing a house fire and is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Atelectasis C. Bronchitis D. Pneumonia
Correct Answer: A. Adult respiratory distress syndrome (ARDS) Severe hypoxia after smoke inhalation is typically related to ARDS. Option B: Atelectasis is not associated with smoke inhalation. Inhaling harmful smoke can inflame the lungs and airway, causing them to swell and block oxygen. This can lead to acute respiratory distress syndrome and failure. Option C: Bronchitis does not develop due to smoke inhalation. However, if the client already has bronchitis, inhalational injuries can worsen its condition. Option D: Pneumonia isn't typically associated with smoke inhalation and severe hypoxia.
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons? A. Alveolar damage in the infarcted area. B. Involvement of major blood vessels in the occluded area. C. Loss of lung parenchyma. D. Loss of lung tissue.
Correct Answer: A. Alveolar damage in the infarcted area. The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Option B: Clot formation usually occurs in the legs. This is called deep vein thrombosis, which occurs in one or more of the deep veins in the legs. Option C: Loss of lung parenchyma is not found with hemoptysis in pulmonary embolism. The lung parenchyma comprises a large number of thin-walled alveoli, forming an enormous surface area, which serves to maintain proper gas exchange. Option D: A regional loss of surfactant is one of the consequences in pulmonary embolism.
When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal. D. Significant; the client has alveolar hypoventilation.
Correct Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Option B: Oxygenation is evaluated through Pao2 and oxygen saturation. Option C: The normal PaCO2 level is between 35 to 45 mmHg. PaCO2 or the partial pressure of carbon dioxide is the measure of carbon dioxide within arterial or venous blood. Option D: Alveolar hypoventilation would be reflected in an increased Paco2. Alveolar hypoventilation is defined as insufficient ventilation leading to hypercapnia, which is an increase in the partial pressure of carbon dioxide as measured by arterial blood gas analysis.
Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture? A. Fracture of the distal radius. B. Fracture of the olecranon. C. Fracture of the humerus. D. Fracture of the carpal scaphoid.
Correct Answer: A. Fracture of the distal radius. Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Option B: Colles' fracture does not involve the olecranon. Most Colles fractures are secondary to a fall on an outstretched hand with a pronated forearm in dorsiflexion. Option C: The humerus is not affected in Colles' fracture. It is a complete fracture of the radius bone of the forearm close to the wrist resulting in an upward displacement of the radius and obvious deformity. Option D: Colles' fracture doesn't refer to a fracture of the carpal scaphoid. A scaphoid fracture is a break in one of the small bones of the wrist.
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test. B. A decreased TSH level. C. An increase in the TSH level after 30 minutes during the TSH stimulation test. D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay.
Correct Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. Option B: A decreased TSH level indicates a pituitary deficiency of this hormone. Option C: If the TSH level rises after 30 minutes, then the client has no hyperthyroidism. Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from the administration of phenytoin and certain other drugs.
Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? A. "Inject insulin into healthy tissue with large blood vessels and nerves." B. "Rotate injection sites within the same anatomic region, not among different regions." C. "Administer insulin into areas of scar tissue or hypertrophy whenever possible." D. "Administer insulin into sites above muscles that you plan to exercise heavily later that day."
Correct Answer: B. "Rotate injection sites within the same anatomic region, not among different regions." The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Option A: Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue, or other deviations. Option C: Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Option D: Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.
When prioritizing care, which of the following clients should the nurse Olivia assess first? A. A 17-year-old client 24-hours post appendectomy. B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome. C. A 50-year-old client 3 days post myocardial infarction. D. A 50-year-old client with diverticulitis.
Correct Answer: B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. Option A: The client who is post appendectomy has no signs of hemorrhage or unstable vital signs. Possible complications of appendectomy are bleeding, wound infection, peritonitis, blocked bowels, and injury to nearby organs. Option C: There's no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. About 90% of patients who have an acute MI develop some form of cardiac arrhythmia during or immediately after the event. Option D: There's no evidence to suggest perforation for the client with diverticulitis as a priority of care. Diverticula are small, bulging pouches that can form in the lining of the digestive system.when one or more of the pouches become inflamed, and in some cases infected, that condition is known as diverticulitis.
Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? A. Pitting edema of the legs B. An irregular apical pulse C. Dry mucous membranes D. Frequent urination
Correct Answer: B. An irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Option A: Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Option C: Dry mucous membranes is not a symptom of Cushing's syndrome. Thinning of the skin and mucous membranes occur because cortisol causes the breakdown of some dermal proteins along with the weakening of small blood vessels. Option D: Frequent urination signals dehydration, which isn't associated with Cushing's syndrome. Short term administration of adrenocorticotropic hormone or glucocorticoids causes an increased glomerular filtration rate. Glomerular dysfunction leads to proteinuria and albuminuria.
Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder? A. Calcium and sodium B. Calcium and phosphorous C. Phosphorus and potassium D. Potassium and sodium
Correct Answer: B. Calcium and phosphorous In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Option A: Sodium increases calcium excretion and higher calcium excretion is associated with lower bone mineral density, a predictor of osteoporotic fractures. Option C: Potassium is not involved in osteoporosis. Potassium salts aid in bone health. A study, published in the journal Osteoporosis International, also revealed that high intake of potassium salts significantly reduces the excretion of calcium and acid in urine. Option D: Sodium, in the form of sodium chloride, elevates urinary calcium excretion and, at prevailing calcium intakes, evokes compensatory responses that may lead to increased bone remodeling and bone loss. However, potassium was inversely associated with both urinary calcium excretion and intestinal calcium absorption, yielding no significant net change in calcium balance.
The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is: A. Anaphylactic shock B. Cardiogenic shock C. Distributive shock D. Myocardial infarction (MI)
Correct Answer: B. Cardiogenic shock Cardiogenic shock is shock related to ineffective pumping of the heart. Option A: Anaphylactic shock results from an allergic reaction. This severe reaction happens when an over-release of chemicals puts the person into shock. Option C: Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. Option D: MI isn't a shock state, though in most cases, a lack of oxygen to the heart, usually from a heart attack, damages its main pumping chamber. Without oxygen-rich blood circulating to that area of the heart, the heart muscle can weaken and go into cardiogenic shock.
Nurse Lourdes is teaching a client recovering from Addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions? A. "I'll take my hydrocortisone in the late afternoon, before dinner." B. "I'll take all of my hydrocortisone in the morning, right after I wake up." C. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." D. "I'll take the entire dose at bedtime."
Correct Answer: C. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. Option A: Taking the medicine at this schedule may cause adverse effects. Option B: The dosage should be according to the imitation of when the body secretes glucocorticoids. Option D: Taking an entire dose might cause severe adverse effects.
JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it's effective for gout? A. Replaces estrogen. B. Decreases infection. C. Decreases inflammation. D. Decreases bone demineralization.
Correct Answer: C. Decreases inflammation. The action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Option A: Colchicine does not replace estrogen. Colchicine works by reducing the inflammation caused by crystals of uric acid in the joints. Option B: Decreasing infection is not a mechanism of action of colchicine. The primary mechanism of action of colchicine is tubulin disruption. This leads to subsequent downregulation of multiple inflammatory pathways and modulation of innate immunity. Option D: Colchicine doesn't decrease bone demineralization. The toxic effects of colchicine are related to this anti-mitotic activity within proliferating tissue such as skin, hair, and bone marrow.
Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma? A. High corticotropin and low cortisol levels B. Low corticotropin and high cortisol levels C. High corticotropin and high cortisol levels D. Low corticotropin and low cortisol levels
Correct Answer: C. High corticotropin and high cortisol levels A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. Option A: Cortisol levels should also be elevated in corticotropin-secreting pituitary adenoma. Option B: Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. Option D: A low corticotropin level with a low cortisol level would be associated with hypocortisolism.
Ruby is receiving thyroid replacement therapy, develops the flu, and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life-threatening complications? A. Exophthalmos B. Thyroid storm C. Myxedema coma D. Tibial myxedema
Correct Answer: C. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. If a person's immune system attacks the thyroid gland, it may react by producing extra hormones. The autoimmune antibodies can attack the muscles and soft tissue surrounding the eyes, which can cause them to protrude from the sockets. Option B: Thyroid storm is life-threatening but is caused by severe hyperthyroidism. It is also referred to as thyrotoxic crisis, an acute, life-threatening hypermetabolic state induced by excessive release of thyroid hormones. Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening
Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate? A. "Your son had a mild concussion, acetaminophen is strong enough." B. "Aspirin is avoided because of the danger of Reye's syndrome in children or young adults." C. "Narcotics are avoided after a head injury because they may hide a worsening condition." D. Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP)
Correct Answer: C. Narcotics are avoided after a head injury because they may hide a worsening condition. Narcotics may mask changes in the level of consciousness that indicate increased ICP. Option A: Acetaminophen is strong enough ignores the mother's question and therefore isn't appropriate. Option B: Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye's syndrome. Option D: Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's: A. Onset to be at 2 p.m. and its peak to be at 3 p.m. B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. D. Onset to be at 4 p.m. and its peak to be at 6 p.m.
Correct Answer: C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. Option A: 2 p.m. is when the insulin was given; onset does not occur at the same time as the medication was given Option B: The peak starts 2 to 4 hours after the insulin was given, which will be at 4 p.m. Option D: Onset of 4 p.m. is very late; 15 to 30 minutes is the expected onset of insulin. Peak shoud start at 4 p.m.
Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct? A. Osteoarthritis is rarely debilitating. B. Osteoarthritis is a rare form of arthritis. C. Osteoarthritis is the most common form of arthritis. D. Osteoarthritis affects people over 60.
Correct Answer: C. Osteoarthritis is the most common form of arthritis Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly. Option A: Osteoarthritis is an extremely debilitating disease. The cartilage within a joint begins to break down and the underlying bone begins to change. Option B: It is the most common form of arthritis. It affects over 32.5 million US adults. Option D: Osteoarthritis can affect people of any age, but are most common among the elderly. Women are more likely to develop QA than men, especially after the age of 50.
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is: A. Elevated serum complement level B. Thrombocytosis, elevated sedimentation rate C. Pancytopenia, elevated antinuclear antibody (ANA) titer D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C. Pancytopenia, elevated antinuclear antibody (ANA) titer Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Option A: Decreased levels of serum complement is usually associated with SLE. The cause of complement activation in SLE is the formation of immune complexes, which in turn activate complement, predominantly by means of the classical pathway. Option B: Thrombocytopenia is one of the components of pancytopenia. It is a condition in which the platelet count is decreased. Option D: Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE. The part of the kidney most frequently troubled by SLE is part of the nephron called the glomerulus, a tuft of capillaries that functions to filter substances from the blood. For this reason, the type of kidney inflammation most commonly experienced in lupus is glomerulonephritis.
A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He's now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions? A. Bronchitis B. Pneumonia C. Pneumothorax D. Tuberculosis (TB)
Correct Answer: C. Pneumothorax Pneumothorax is defined as the presence of air or gas in the pleural cavity, which can impair oxygenation and/or ventilation. Option A: Rhonchi is heard with bronchitis. Option B: From the trauma the client experienced, it's unlikely he has pneumonia. Pneumonia may produce crackling, bubbling, and rumbling sounds when inhaling upon auscultation. Option D: Bronchial breath sounds with TB would be heard.
If a client requires a pneumonectomy, what fills the area of the thoracic cavity? A. The space remains filled with air only. B. The surgeon fills the space with a gel. C. Serous fluids fill the space and consolidate the region. D. The tissue from the other lung grows over to the other side.
Correct Answer: C. Serous fluids fill the space and consolidate the region Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Option A: Air can't be left in space. Air in the chest cavity is called a pneumothorax, and it may cause the lungs to collapse. Option B: There's no gel that can be placed in the pleural space. The pleural cavity is the space that lies between the pleura, the two thin membranes that line and surround the lungs. It contains a small amount of liquid known as pleural fluid. Option D: The tissue from the other lung can't cross the mediastinum, although a temporary mediastinal shift exists until space is filled.
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? A. Elevated serum acetone level. B. Serum ketone bodies. C. Serum alkalosis. D. Below-normal serum potassium level.
Correct Answer: D. Below-normal serum potassium level. A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. Option A: An elevated serum acetone level is a symptom of diabetic ketoacidosis. Hepatic metabolism of free fatty acids as an alternative energy source results in accumulation of acidic intermediate and end metabolites (ie, ketones). Ketone bodies have generally included acetone, a true ketone. Option B: Serum ketone bodies are characteristic of diabetic ketoacidosis. Ketone bodies are produced from acetyl coenzyme A mainly in the mitochondria within hepatocytes when carbohydrate utilization is impaired because of relative or absolute insulin deficiency, such that energy must be obtained from fatty acid metabolism. Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS. A wide anion gap can be observed in patients with HHNS. The mild acidosis in HHNS is often multifactorial and results, in part, from the accumulation of minimal ketoacids in the absence of effective insulin activity.
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus? A. Above-normal urine and serum osmolality levels. B. Below-normal urine and serum osmolality levels. C. Above-normal urine osmolality level, below-normal serum osmolality level. D. Below-normal urine osmolality level, above-normal serum osmolality level.
Correct Answer: D. Below-normal urine osmolality level, above-normal serum osmolality level In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. Option A: Urine osmolality level should be below normal because of excessive polyuria. Option B: Serum osmolality levels should be above normal because of dehydration. Option C: For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels.
A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? A. Asthma attack B. Atelectasis C. Bronchitis D. Fat embolism
Correct Answer: D. Fat embolism Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. Option A: Asthma attacks do not develop following a femoral fracture. Option B: He could develop atelectasis but it typically doesn't produce progressive hypoxia. Option C: It's unlikely the client has developed bronchitis without a previous history.
A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders? A. Diabetes mellitus B. Diabetes insipidus C. Hypoparathyroidism D. Hyperparathyroidism
Correct Answer: D. Hyperparathyroidism Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria. Option A: Common symptoms of diabetes mellitus include polyuria, polydipsia, and polyphagia Option B: While clients with diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Option C: Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is: A. It dilates peripheral blood vessels. B. It decreases sympathetic cardio acceleration. C. It inhibits the angiotensin-converting enzymes. D. It inhibits the reabsorption of sodium and water in the loop of Henle.
Correct Answer: D. It inhibits the reabsorption of sodium and water in the loop of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Option A: Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Option B: Adrenergic blockers decrease sympathetic cardio acceleration and decrease blood pressure. Option C: Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
For a client with Graves' disease, which nursing intervention promotes comfort? A. Restricting intake of oral fluids. B. Placing extra blankets on the client's bed. C. Limiting intake of high-carbohydrate foods. D. Maintaining room temperature in the low-normal range.
Correct Answer: D. Maintaining room temperature in the low-normal range. Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Option B: Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. Option C: To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods
A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following? A. Testing for ketones in the urine. B. Testing urine specific gravity. C. Checking temperature every 4 hours. D. Performing capillary glucose testing every 4 hours.
Correct Answer: D. Performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Option A: Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Option B: Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Option C: Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection.
A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax
Correct Answer: D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. Option A: An asthma attack would show wheezing breath sounds. Option B: Bronchitis would have rhonchi. Option C: Pneumonia would have bronchial breath sounds over the area of consolidation.
