Physiological Adaptation: Remediation

The nurse plans to teach a group of older adult clients with diabetes mellitus (DM) about ways to maintain glycemic control. Which strategies will the nurse reinforce? (Select all that apply.) 1. Monitor blood glucose levels on a prescribed basis. 2. Participate in a regular exercise program. 3. Lose weight by eating a low carbohydrate diet. 4. Improve self-care through education about diabetes. 5. Limit the total intake of dietary cholesterol.

1) CORRECT - Consistently monitoring blood glucose levels on a prescribed basis is essential for maintaining glycemic control. 2) CORRECT - Regular exercise lowers blood glucose levels by increasing the uptake of glucose by muscles. 3) INCORRECT - Weight loss is not needed for all clients with diabetes mellitus. More calories should come from carbohydrates, especially complex carbohydrates, than from fats and proteins. 4) CORRECT - It is essential to understand diabetes mellitus and strategies to maintain appropriate glycemic levels. 5) CORRECT - The total intake of dietary cholesterol should be less than 300 mg/day. Clients with diabetes mellitus may be at a higher risk of cardiac disease.

The nurse provides education to a client who is newly diagnosed with systemic lupus erythematosus (SLE). Which client statement indicates to the nurse a need for further instruction? (Select all that apply.) 1. "I will wear SPF 15 sunscreen when I am outside." 2. "Nonsteroidal anti-inflammatory medications may help decrease my joint pain." 3. "The rash on my face will go away in time." 4. "I may need to take a medication that will boost my immune system." 5. "I will wear a long-sleeved shirt while gardening."

1) CORRECT - Individuals with SLE should wear sunscreen with a minimum SPF of 30 when exposed to direct sunlight. 2) INCORRECT - With SLE, bone and joint pain is a common manifestation. Regular use of nonsteroidal anti-inflammatory medication may help with pain control. 3) CORRECT - The characteristic "butterfly" pattern rash associated with SLE is permanent and does not resolve with time. 4) CORRECT - Treatment of SLE may include the use of immunosuppressive medications in order to prevent a systemic response to the illness. 5) INCORRECT - To protect skin integrity, the individual with SLE should wear a long-sleeved shirt, full pants, and a broad-brimmed hat when exposed to direct sunlight. Systemic lupus erythematosus is a multisystem, autoimmune disease that may affect skin, joints, mucous membranes, heart, lungs, kidneys, nervous system, and all the blood cell lines. Symptoms can be mild or severe and tend to come and go over time. Common symptoms include painful joints, fevers, rashes caused by sun exposure, hair loss, loss of circulation in toes or fingers, swelling in the legs, ulcers inside the mouth, swollen glands, and extreme tiredness. Treatment depends on symptoms and symptom severity, but may include anti-inflammatory medications, anti-malarial medications, corticosteroids, immunosuppressive medications, anticoagulants, and monoclonal antibodies.

The nurse provides care for a client experiencing diabetic ketoacidosis (DKA). Which findings will the nurse expect when assessing this client? (Select all that apply.) 1. Poor skin turgor. 2. Decreased urine output. 3. Elevated blood glucose. 4. Tachycardia. 5. Orthostatic hypotension.

1) CORRECT - Poor skin turgor results from the dehydration that occurs in DKA. 2) INCORRECT - The client would experience polyuria because the body attempts to rid itself of glucose through the kidneys. 3) CORRECT - Elevated blood glucose levels result from the profound deficiency of insulin. 4) CORRECT - Tachycardia results from the dehydration that occurs in DKA. Tachycardia is a compensatory mechanism to keep the cardiac output adequate in times of fluid volume deficit. 5) CORRECT - DKA results in dehydration. Fluid is eliminated by the kidneys in an attempt to excrete the high levels of glucose. Dehydration causes orthostatic hypotension.

The nurse provides care for a client in the first trimester of pregnancy who is diagnosed with hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and a chloride deficiency. Which action should the nurse implement first? 1. Start an intravenous fluid. 2. Complete an intake and output record every 4 hours. 3. Provide oral fluids every hour. 4. Perform a weight check every morning.

1) CORRECT — Parenteral hydration is the best way to rehydrate the client. 2) INCORRECT — Intake and output recording will be part of the plan to evaluate the status of hydration for this client. 3) INCORRECT — The client will initially be NPO to rest the gastrointestinal tract. 4) INCORRECT — This is an appropriate action for evaluating the client, but it does not meet the immediate hydration needs. Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, dehydration, electrolyte imbalances, and weight loss. Monitor the client's vital signs, weight, and laboratory test results to evaluate the effectiveness of treatment. Administer IV fluids, electrolyte replacement, and antiemetics as prescribed. Provide nutritional instructions to the client. Good nutritional intake during pregnancy consists of consuming approximately 300 extra calories daily to maintain a healthy pregnancy. The extra calories should come from a balanced diet of fruits, vegetables, protein, and whole grains, while those from dietary fats and sweets should be minimal.

A client develops post-concussion syndrome caused by a head injury sustained from a fall. For which client statements will the nurse intervene? (Select all that apply.) 1. "The concussion showed up on the head computed tomography scan." 2. "I may have a persistent headache for 2 weeks or longer." 3. "I should notify the health care provider if I have repeated episodes of vomiting." 4. "I can immediately resume contact sports at school." 5. "I may have trouble remembering details from one day to the next." 6. "I have no recollection of the events surrounding the incident."

1) CORRECT— A concussion does not appear on a head computed tomography scan. Concussion is a clinical diagnosis based upon symptoms. 2) INCORRECT - The client recovering from a concussion may have a persistent headache that lasts for 2 weeks or longer. 3) INCORRECT - Repeated and continuous bouts of vomiting after a concussion may indicate that the condition is worsening or intracranial pressure is increasing, and should be reported to the health care provider. 4) CORRECT— After a head injury, the client should refrain from contact sports due to the risk of reinjury and worsening of the condition until it has cleared. 5) INCORRECT - Inability to remember daily details is a common finding in post-concussion syndrome. 6) INCORRECT - Amnesia about the event that caused the head injury is a common finding in post-concussion syndrome.

The nurse observes prominent U waves on a client's electrocardiogram (ECG) rhythm strip. Based on this abnormality, for which condition will the nurse assess the client? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Hypercalcemia.

1) CORRECT— Prominent U waves on a client's ECG strip signal hypokalemia, an abnormally low serum potassium level. 2) INCORRECT - Hyperkalemia, an abnormally high serum potassium level, causes P-wave flattening, QRS complex widening, and peaking of the T waves. 3) INCORRECT - The QT interval and ST segment may be prolonged with hypocalcemia, an abnormally low calcium level. Torsades de pointe, a lethal ventricular arrhythmia, also may occur with hypocalcemia. 4) INCORRECT - Shortening of the QT interval and ST segment may occur with hypercalcemia, an abnormally high serum calcium level.

The nurse provides care for a client who has just been intubated in preparation for mechanical ventilation. Which action does the nurse take next? 1. Assess lung sounds. 2. Call for a stat x-ray. 3. Obtain arterial blood gases. 4. Suction the endotracheal tube.

1) CORRECT— The priority is to assess for bilateral lung sounds and bilateral chest excursions. Always assess before implementing. 2) INCORRECT - A chest x-ray is obtained for radiographic confirmation after an initial verification of placement by auscultation. 3) INCORRECT - Arterial blood gases will not demonstrate meaningful change until the client is ventilated. Without needed ventilation, ABG values will continue to deteriorate. 4) INCORRECT - The nurse ensures the tube is providing an adequate airway and then suctions secretions from the tube if needed. The priority is to verify proper placement of the endotracheal (ET) tube immediately after intubation. The most reliable method is to obtain a chest radiography to verify placement of the ET tube. While waiting for the chest x-ray, the nurse can listen for bilateral breath sounds and adequate air entry. Quantitative waveform capnography (monitoring the partial pressure of carbon dioxide CO 2) can also be obtained if the equipment is available.

The nurse provides care for a client diagnosed with chronic venous insufficiency. Which findings does the nurse note as being consistent with this diagnosis? (Select all that apply.) 1. Thick, dark skin on bilateral lower extremities. 2. Varicose veins in the right leg. 3. Pain in the lower extremities while sitting. 4. A tender, red area on one lower extremity. 5. Crater-like lesions on the lower extremities.

1) CORRECT— Thick, dark skin on the lower extremities is consistent with the diagnosis of chronic venous insufficiency. Chronic edema causes changes in consistency and color of the skin. 2) CORRECT— Varicose veins are consistent with the diagnosis of chronic venous insufficiency. 3) CORRECT— Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions. 4) INCORRECT— A tender area describes phlebitis, not venous insufficiency. This finding is inconsistent with the diagnosis of chronic venous insufficiency. 5) CORRECT — This finding is consistent with the diagnosis of chronic venous insufficiency. Crater-like lesions on the lower legs describes venous stasis ulcers.

The nurse assesses the client diagnosed with seizures, migraines, and type 1 diabetes mellitus (DM). Which client statement requires follow up by the nurse? (Select all that apply.) 1. "I see fireflies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." 4. "I usually give myself the insulin." 5. "I usually sleep after a seizure."

1) CORRECT— This client statement requires follow up by the nurse. Flashing lights may indicate aura before the seizure or a migraine. 2) CORRECT— This client statement requires follow up by the nurse. Hypersomnia or fatigue may indicate hyperglycemia, an adverse effect of poorly managed type 1 DM. 3) CORRECT— This client statement requires follow up by the nurse. Tremors may be associated with hypoglycemia, an adverse effect associated with type 1 DM. 4) INCORRECT — Promotion of independence in performing self-care is appropriate. 5) INCORRECT — Postictal confusion and sleepiness is common.

A client who follows a lacto-vegetarian eating plan receives discharge teaching for extremity and head wounds caused by a bicycle accident. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.) 1. "I should increase my intake of tofu, beans, nuts, and seeds." 2. "I should increase my intake of milk, oatmeal, and peanuts." 3. "It would be good to have an omelet for breakfast." 4. "I should decrease my intake of tomatoes and orange juice." 5. "Since I am less active now, I should decrease the number of calories I eat per day."

1) CORRECT— This statement indicates a correct understanding of the teaching presented. Protein is important for wound healing. Tofu, beans nuts, and seeds are all foods high in protein. 2) CORRECT — This statement indicates a correct understanding of the teaching presented. Vitamin B6 and B12 are important for collagen synthesis and are present in milk, oatmeal, and peanuts. Milk and peanuts also have protein, which is essential for wound healing. 3) INCORRECT - Protein is good for wound healing, but eggs are not a part of a lacto-vegetarian eating plan. Therefore, this statement indicates the need for further education. 4) INCORRECT - Foods high in vitamin C should be encouraged for wound healing. Therefore, this statement indicates the need for further education. 5) INCORRECT - Calories should be increased to promote wound healing. Therefore, this statement indicates the need for further education.

The nurse provides care for a client diagnosed with multiple sclerosis (MS). When completing a physical assessment, which clinical manifestations does the nurse expect to see? (Select all that apply.) 1. Urinary retention. 2. Decreased level of consciousness. 3. Photophobia. 4. Intestinal obstruction .5. Ataxic movements. 6. Short term memory loss.

1) CORRECT— Urinary retention is caused by progressive demyelination of the spinal cord. This leads to an alteration in the innervation of bladder and urinary tract, causing urinary retention. The nurse anticipates this clinical manifestation upon assessment. 2) INCORRECT— Decreased level of consciousness is not a clinical manifestation associated MS. The nurse should not expect to see this symptom. 3) INCORRECT— Photophobia is not a clinical manifestation associated with MS. The nurse should not expect to see this symptom. 4) INCORRECT— Peristalsis is not a clinical manifestation associated with MS. The nurse should not expect to see this clinical manifestation. 5) CORRECT— Ataxia is defined as shaky, uncoordinated, and/or irregular movements, a clinical manifestation associated with MS; therefore, nurse anticipates this clinical manifestation upon assessment. 6) CORRECT— A cognitive change, such as short term memory loss, is a clinical manifestation associated with MS; therefore, nurse anticipates this clinical manifestation upon assessment. Multiple sclerosis (MS) is an autoimmune disorder in which progressive damage to the myelin sheath in the central nervous system results in slowing or stopping of nerve impulses. This causes neurological problems and mobility issues. The course of MS varies, but most clients experience episodic exacerbations alternating with remissions. Eventually, demyelination results in significant loss of functioning. Early symptoms of MS include vision problems such as color blindness, loss of sight in one eye, blurred and/or double vision. Fatigue, weakness, paresthesias, vertigo, and ataxia often occur, and bowel and bladder dysfunction may be present.

The nurse provides care for a client with an exacerbation of ulcerative colitis. The nurse determines teaching is effective when the client makes which dietary choice? (Select all that apply.) 1. Meatless chili with lentils and kidney beans. 2. A multigrain sandwich with lean turkey and alfalfa sprouts. 3. Canned green beans and applesauce. 4. Carrots and celery sticks with vegetable dip. 5. Grilled cheese sandwich on white bread with creamed tomato soup. 6. Roast beef and mashed potatoes.

1) INCORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Beans and legumes are high in fiber, which would be contraindicated for this client. This dietary choice indicates that the client needs additional teaching. 2) INCORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Whole grains and raw vegetables, such as sprouts, are contraindicated. This dietary choice indicates that the client needs additional teaching. 3) CORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Canned, cooked, and seedless vegetables without skins are permitted on a low-residue diet. This dietary choice indicates understanding by the client. 4) INCORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Raw vegetables are contraindicated for this client. This dietary choice indicates that the client needs additional teaching. 5) CORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Refined grains are permitted, as well as cheese and milk. This dietary choice indicates understanding by the client. 6) CORRECT - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Meats and cooked skinless vegetables are permitted. This dietary choice indicates understanding by the client.

The nurse provides care to a client reporting a cluster headache. Which nursing action is appropriate when providing care for this client? 1. Prepare for a head CT scan. 2. Administer 100% oxygen via facemask. 3. Measure erythrocyte sedimentation rate. 4. Withhold prescribed sublingual sumatriptan.

1) INCORRECT - A head CT scan is not indicated for a typical cluster headache. 2) CORRECT — Acute treatment of a cluster headache includes the provision of 100% oxygen delivered at a rate of 6 to 8 liters per minute for 10 minutes. This may be repeated after a 5-minute rest. Oxygen relieves the headache by causing vasoconstriction and increasing the synthesis of serotonin in the central nervous system. 3) INCORRECT - The erythrocyte sedimentation rate is an inflammatory marker and is not indicated for a cluster headache. 4) INCORRECT - Sumatriptan is effective in treating acute cluster headaches and should be administered, not withheld.

A university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which action should the nurse take first? 1. Ask if the student has experienced this problem previously. 2. Obtain the student 's temperature. 3. Encourage the student to drink large volumes of fluid. 4. Insist that the police override the curfew and allow travel.

1) INCORRECT - A health history is relevant but not the first action. It does nothing to relieve the client's discomfort. 2) INCORRECT - The student is exhibiting the symptoms of a urinary tract infection (UTI). Fever is a rare manifestation of UTI. 3) CORRECT— The client's symptoms are consistent with a urinary tract infection (UTI), and fluids will help flush the system and may relieve some discomfort. A warm sitz bath may also help relieve discomfort. Antibiotics, the treatment of choice for a UTI, can be obtained after curfew. 4) INCORRECT - The client has reported symptoms consistent with a urinary tract infection, which is not life threatening.

The nurse provides care to an adolescent client diagnosed with acute glomerulonephritis. The parents ask the nurse what to expect regarding management of this diagnosis. Which information does the nurse provide to the family? 1. "Your child will likely require a nephrectomy." 2. "Your child will be prescribed chemotherapy." 3. "Your child will likely require peritoneal dialysis." 4. "Your child will be prescribed diuretic therapy."

1) INCORRECT - A nephrectomy is usually not required for a client with acute glomerulonephritis. 2) INCORRECT - Acute glomerulonephritis is usually treated with anti-infectives, diuretics, and antihypertensives, but not with chemotherapeutic agents. 3) INCORRECT - Chronic glomerulonephritis may be treated using peritoneal dialysis if end-stage kidney disease develops, but acute glomerulonephritis does not require dialysis. 4) CORRECT— Acute glomerulonephritis is usually treated with anti-infectives, diuretics, and antihypertensives, which will be given at home as soon as the client is stable and discharged home.

The nurse teaches a client diagnosed with Addison disease about the health condition. Which client statements indicate to the nurse that teaching is effective? (Select all that apply.) 1. "The disease is characterized by secretion of too many hormones." 2. "My own antibodies probably destroyed my adrenal tissue. "3. "I now have to follow a low-sodium diet." 4. "Stress may trigger an Addisonian crisis." 5. "I have increased adrenocorticotropic hormone levels. "6. "Treatment for my disease will place me at greater risk for diabetes mellitus."

1) INCORRECT - Addison disease is characterized by a deficiency in glucocorticoids, mineralocorticoids, and androgens. 2) CORRECT— An autoimmune response is the most common cause of Addison disease in the United States. Other causes include tuberculosis, infarction, fungal infections, acquired immunodeficiency syndrome (AIDS), and metastatic cancer. 3) INCORRECT - Hyponatremia is a common laboratory finding in a client diagnosed with Addison disease. The client should not follow a low-sodium diet. 4) CORRECT— Stress from an infection or surgery and psychological stress can trigger an Addisonian crisis. 5) CORRECT— Adrenocorticotropic hormone levels increase in primary adrenal insufficiency or Addison disease. 6) CORRECT— Corticosteroids used to treat Addison disease can lead to glucose intolerance and predispose a client to developing diabetes mellitus.

The nurse provides teaching for a client diagnosed with liver cirrhosis. Which statements by the client cause the nurse to determine that teaching is effective? (Select all that apply.) 1. "I will use a medium- or hard-bristle toothbrush." 2. "I will limit myself to one serving of alcohol per day." 3. "I will eat no more than 1200 calories per day." 4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider."

1) INCORRECT - Bleeding is common due to decreased production of clotting factors such as thrombin and fibrin. A client should only use a soft-bristle toothbrush, to minimize the risk of bleeding. 2) INCORRECT - A client should completely abstain from alcohol use with this diagnosis. 3) INCORRECT - Malnutrition is a serious clinical problem associated with cirrhosis. The diet for client with cirrhosis, without complications, should be high in calories, up to 3000 calories each day. 4) CORRECT— Applying calamine lotion is an appropriate action. The client may have pruritus accompanied by jaundice, which makes the skin dry and itchy. 5) CORRECT— Melena (black, tarry stools) should be reported to the health care provider immediately as it can indicate bleeding esophageal varices. Cirrhosis is a chronic, degenerative liver disorder caused by hepatic cell damage. Cirrhosis affects metabolic, coagulation, and detoxifying functions. Tactfully explore the client's lifestyle history, including alcohol and drug use. Assess for right upper quadrant pain, weight loss, weakness, anorexia, elevated blood pressure, ascites, splenomegaly, jaundice, abnormal bleeding, pruritus, clay-colored stools, and altered fluid and electrolyte levels. Weigh the client daily, calculate intake and output, measure abdominal girth, institute bleeding precautions, and monitor coagulation studies and ammonia levels. Also provide a high-calorie, low-sodium, low-protein diet.

A client is tested for suspected amyotrophic lateral sclerosis (ALS). Which early symptom will the nurse expect the client to exhibit? 1. Incontinence of bowel and bladder. 2. Difficulty swallowing. 3. Paresthesia of the face . 4. Disorientation to time and place.

1) INCORRECT - Bowel and bladder function is retained with ALS. 2) CORRECT— ALS affects the muscles of the throat and upper respiratory tract. The client will demonstrate dysphagia, which can cause aspiration. Other early symptoms include fatigue while talking, tongue atrophy, and weakness of the hands and arms. 3) INCORRECT - ALS causes facial fasciculations and not paresthesias. 4) INCORRECT - ALS does not affect mental status or cognition.

The nurse in the emergency department provides care for a client with a bee sting. The nurse notes the client is sneezing and coughing, is flushed, has hives, and reports feeling warm. Which action does the nurse take first? 1. Continue to monitor the client. 2. Immediately administer prednisone. 3. Establish an intravenous normal saline infusion. 4. Ask the client about previous reactions to bee stings.

1) INCORRECT - Monitor the client for reaction progression and indications of anaphylactic reaction. Be prepared to establish an airway. 2) INCORRECT - After the intravenous line is established, IV corticosteroids are given to prevent or reverse the hypersensitivity response by suppressing the immune reaction. 3) CORRECT - The priority is to monitor and support the client's circulatory status, maintain blood pressure, and provide IV access for emergency drug administration. 4) INCORRECT - Asking the client for a history is appropriate when trying to prevent anaphylactic reaction. However, the physiological status should be supported based on assessment findings regardless of history.

The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select all that apply. ) 1. Urine specific gravity is 1.039. 2. Azotemia. 3. Pruritus. 4. Nausea. 5. Serum potassium (K+) is 6 mEq/L (6 mmol/L).

1) INCORRECT - Normal urine specific gravity ranges from 1.010 to 1.030. During the oliguric phase of acute renal failure, urine specific gravity typically decreases (if the primary cause is prerenal) or remains within normal limits (if the primary cause is intrarenal). 2) CORRECT - Azotemia, which is a classic sign of acute renal failure, refers to the buildup of nitrogenous waste products in the bloodstream. Hallmarks of azotemia include increased serum BUN and increased serum creatinine. 3) CORRECT - With acute renal failure, pruritus (itching) may occur. Although some scientists believe a buildup of urea in the bloodstream contributes to this condition, research has not yet conclusively identified the cause of pruritus in relationship to kidney dysfunction. 4) CORRECT - With acute renal failure, the buildup of metabolic waste products in the bloodstream may cause nausea and vomiting. 5) CORRECT - Normal potassium ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Acute renal failure causes impaired filtration of fluid and electrolytes. During the oliguric phase, an increase in serum potassium (hyperkalemia) is typically seen.

A client diagnosed with arterial insufficiency calls the nurse in the outpatient clinic and reports being awakened at night by lower extremity pain. Which suggestion by the nurse is best? 1. Elevate both legs on two pillows. 2. Sit on the side of the bed. 3. Place a bed cradle over the legs. 4. Wear cotton pants to keep the legs warm.

1) INCORRECT - Pain with arterial insufficiency is related to cellular hypoxia due to decreased blood flow. Elevating the legs promotes venous return but decreases arterial flow to the lower extremities. This will worsen the client 's pain. 2) CORRECT— Lowering the legs over the side of the bed enhances arterial blood supply and oxygen to the lower legs. This will help with the client 's pain. 3) INCORRECT - This prevents pressure on the legs, but it does not promote arterial circulation to the lower extremities and is unlikely to assist with the pain. 4) INCORRECT - While cotton pants may decrease the risk of vasoconstriction related to cold temperatures, it does not improve the blood flow to the lower extremities. Having the client dangle the legs below the level of the heart will increase blood flow to the lower extremities and resolve the client 's pain.

The nurse becomes concerned when which client makes the statement, "I've had leg spasms that kept me awake all night, and now I can't feel my hands and feet!"? (Select all that apply.) 1. A client with small cell lung cancer. 2. A client with stage IV breast cancer with metastasis to the bone. 3. A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours. 4. A client with acute pancreatitis due to medication toxicity. 5. A client following surgery for removal of the thyroid gland.

1) INCORRECT - Small cell lung cancer is associated with paraneoplastic syndrome, which includes ectopic secretion of the parathyroid hormone. This increases blood calcium or hypercalcemia. 2) INCORRECT - Cancers in the bone cause the bone to excrete calcium, which is absorbed in the bloodstream, leading to high serum calcium levels or hypercalcemia. 3) CORRECT - During the polyuric phase of acute kidney injury, calcium is excreted at a higher than normal rate, leading to hypocalcemia. 4) CORRECT - Acute pancreatitis leads to hypocalcemia, as calcium is bound with fatty acids. 5) CORRECT - The risk of damage to the parathyroid gland in thyroidectomy clients places them at risk for hypocalcemia.

The home care nurse visits an older adult client with a recent history of a cerebrovascular accident (CVA) resulting in a neurogenic bladder. The client is incontinent and has developed repeated urinary tract infections (UTI). Which action by the nurse is most appropriate? 1. Teach the client exercises to strengthen the pelvic floor. 2. Perform an intermittent catheterization for residual urine. 3. Assess the client's fluid intake over the last 48 hours. 4. Teach the client about high fiber dietary intake.

1) INCORRECT - The exercises are appropriate for stress incontinence. A neurogenic bladder is caused by damage to upper motor neurons and interruption in corticospinal nerve pathways that results in urinary retention. 2) CORRECT— Even though a client with a neurogenic bladder is incontinent, the bladder may not be empty completely. Residual urine can cause a UTI. 3) INCORRECT - The client's fluid intake would be assessed but is not a priority. 4) INCORRECT - It would appropriate for the nurse to assess the client's fiber intake and provide teaching as needed, but this is not a priority. Constipation may contribute to incontinence.

he nurse notes that a client, experiencing dull pain in the anterior and posterior neck, has full neck range of motion and no throat redness or enlargement of the head or neck lymph nodes. Which assessment will the nurse complete next? 1. Examination of the ears. 2. Palpation of the liver. 3. Auscultation of heart sounds. 4. Auscultation of bowel sounds.

1) INCORRECT - There is no direct correlation between the ears and the pain reported. 2) CORRECT - The right neck and the flank are common areas of referred pain from liver damage, so the liver should be examined when dull pain in the anterior and posterior neck occurs. 3) INCORRECT - The heart does not correlate with the reported area of pain. 4) INCORRECT - The gastrointestinal tract does not correlate with the reported area of pain. The client with liver disease may experience weight loss, weakness, anorexia, edema, elevated blood pressure, presence of ascites, splenomegaly, abnormal bleeding, jaundice, pruritus, clay-colored stools, elevated ammonia levels, confusion, and altered fluid and electrolyte levels. Liver disease often results in right upper quadrant pain, but the client may experience referred pain, felt in the right flank, shoulder, or neck. The client is at risk for altered metabolism and bleeding due to impaired liver function.

A pediatric client is admitted to the cardiology unit after experiencing sudden chest pain and dizziness. A diagnosis of supraventricular tachycardia (SVT) is made. If the client experiences another episode of chest pain and dizziness, which action does the nurse implement? 1. Place the client in a supine position with arms to the side, and elevate the foot of the bed. 2. Instruct the client to assume a squatting position with the arms wrapped around the legs. 3. Encourage the client to lie on the side and picture walking through a meadow, breathing in slowly through the nose and out through the mouth. 4. Ask the client to stick the thumb in the mouth, close the mouth around it, and then blow on the thumb as if it were a trumpet.

1) INCORRECT - This action would be useful for increasing venous return in peripheral vascular disease (PVD), but is not helpful for the client diagnosed with SVT. 2) INCORRECT - This position is assumed by clients diagnosed with congenital heart disease, particularly Tetralogy of Fallot, in an effort to relieve hypoxia. However, it is not helpful for the client diagnosed with SVT. 3) INCORRECT - Imagery and relaxed controlled breathing can help decrease anxiety and increase relaxation and sense of control, but will not resolve the SVT. 4) CORRECT - This is a form of the vagal or Valsalva maneuver, which can stop SVT. Blowing should occur for 30 to 60 seconds. Other possible vagal maneuvers include ice to the face, holding the breath and then bearing down, or massaging the carotid artery on only one side of the neck. If vagal maneuvers do not work, intravenous adenosine, an anti-dysrhythmic agent, may be given.

The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse? 1. Redness and swelling with fluid-filled vesicles noted on right arm. 2. Charred, waxy, white appearance of skin on the left leg. 3. Reddened blotchy painful areas noted on the trunk. 4. Blistering and blanching of the skin noted on the back.

1) INCORRECT - This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large, thick-walled blisters develop and the underlying tissue is deep red and appears wet and shiny. The damaged skin is painful with increased sensitivity to heat. Healing occurs by evolution of undamaged basal cells and takes about 21 to 22 days. 2) CORRECT— This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved. The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal spontaneously and require grafting. All functions of the skin are lost. 3) INCORRECT - This describes a superficial burn. The skin appears pink and has increased sensitivity to heat. Healing occurs without treatment. 4) INCORRECT - This describes a partial-thickness burn.

The nurse provides care for a client 2 hours after placement of a cuffed tracheostomy tube. When the nurse enters the client's room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first? 1. Place oxygen at 6 L per minute over the stoma opening. 2. Auscultate bilateral breath sounds. 3. Check the client's pulse oxygenation reading. 4. Use a hemostat to dilate the opening of the stoma.

1) INCORRECT - Unless the airway is opened, the client will not be able to access the oxygen. With a newly placed tracheostomy, the stoma will not stay open. The nurse should first dilate the opening of the stoma, and then place oxygen. 2) INCORRECT - This assessment is not relevant at this time, as the client cannot breathe with a closed stoma. 3) INCORRECT - This assessment is not relevant at this time, as the issue is that the client does not have a patent airway. The nurse should first establish an airway. 4) CORRECT— The client's issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize hemostats to open the airway.

The nurse provides care to a client diagnosed with Paget disease. Which findings are anticipated by the nurse as characteristic of this disorder? (Select all that apply.) 1. A vitamin D deficiency. 2. An elevated serum alkaline phosphatase. 3. A pathologic fracture. 4. A loss of total bone mass and substance. 5. An abnormal remodeling and resorption of bone.

1) INCORRECT - Vitamin D deficiency is seen in osteomalacia that causes generalized bone decalcification with bone deformity. 2) CORRECT - An elevated serum alkaline phosphatase level occurs in advanced forms of the disease. 3) CORRECT - Pathologic fractures are the most common complication of the disease. 4) INCORRECT - Loss of total bone mass and substance is seen in osteoporosis. 5) CORRECT - Abnormal remodeling and resorption of bone occurs, and the new bone is larger, disorganized, and structurally weaker.

The nurse provides care for a client diagnosed with rheumatic fever. Which information is priority for the nurse to obtain when completing the client's health history? 1. History of diabetes mellitus. 2. Recent symptoms of pharyngitis. 3. Chest pain with activity. 4. Edema to legs bilaterally.

1) INCORRECT — Having diabetes mellitus is not a risk factor associated with rheumatic fever. Although it is important to determine if the client has diabetes mellitus, it is not priority related to the diagnosis of rheumatic fever. 2) CORRECT — Rheumatic fever typically begins 1-6 weeks after having pharyngitis or strep throat. It is priority to determine if the client had symptoms of pharyngitis when completing the client's health history. 3) INCORRECT — Although it is important to determine if the client is experiencing chest pain with activity, it is priority to identify if the client had symptoms of pharyngitis. Rheumatic fever develops following pharyngitis. 4) INCORRECT — Edema to legs bilaterally is not a clinical manifestation associated with rheumatic fever.

The nurse supervises a nursing team that consists of nurses, LPN/LVNs, and unlicensed assistive personnel (UAP). A client experiences a generalized tonic-clonic seizure while in a standing position and is assisted to the floor. The nurse intervenes if which actions are observed? (Select all that apply.) 1. The LPN/LVN loosens the client's constrictive clothing. 2. The UAP places a pillow under the client's head. 3. The nurse suctions secretions in the buccal cavity. 4. The LPN/LVN places the client in the supine position .5. The UAP restrains the client's extremities during the seizure. 6. The UAP closes the client's curtain until the situation resolves.

1) INCORRECT- Loosening the client's clothing is an action that promotes safety and helps breathing. This action is appropriate and does not require intervention by the nurse. 2) INCORRECT - Placing a pillow under the client's head is an action that promotes safety. This action is appropriate and does not require intervention by the nurse. 3) INCORRECT - Suctioning oral secretions is an action that promotes safety by clearing secretions. This action is appropriate and does not require intervention by the nurse. 4) CORRECT - If possible, the client should be placed on one side with head flexed forward, as this position allows the tongue to fall forward and facilitates drainage of saliva and mucus. The nurse intervenes if supine positioning is observed. 5) CORRECT - Muscular contractions during seizures are strong, and restraint can cause injury to the client and to personnel. The nurse intervenes if this action is observed. 6) INCORRECT - Closing the client's curtain is an action that provides privacy for the client. This action is appropriate and does not require intervention by the nurse.

The nurse provides care for a client diagnosed with myasthenia gravis. When completing a physical assessment, which clinical manifestations does the nurse expect to see? (Select all that apply.) 1. Rigidity.2. Muscle weakness.3. Facial paralysis.4. Propulsive gait.5. Ptosis.6. Diplopia.

1) INCORRECT— Rigidity is a clinical manifestation seen with Parkinson disease, not myasthenia gravis. 2) CORRECT— Muscle weakness is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. 3) INCORRECT— Facial paralysis is a clinical manifestation seen with Bell palsy, not myasthenia gravis. 4) INCORRECT— A propulsive gait is seen with Parkinson disease and is not associated with myasthenia gravis. 5) CORRECT— Ptosis, or drooping eyelids, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. 6) CORRECT— Diplopia, or double vision, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. Guillain-Barré syndrome is an autoimmune disorder that manifests as an acute inflammatory polyneuropathy. Treatment is focused on supportive care and reducing the severity and potential complications of the disease. If initiated within the first 4 weeks of the disease process, plasmapheresis or high doses of intravenous immunoglobulin are effective in reducing recovery time. Problems associated with immobility must be addressed and managed. These include diminished respiratory ventilation effort, stasis of respiratory secretions, nutritional and fluid needs, deep vein thrombosis, development of pressure injuries, and pain management.

The nurse provides care for a client with a hemoglobin level of 6.8 g/dL (68 g/L). Which intervention does the nurse implement first when providing care for this client? 1. Draw a type and crossmatch for 2 units of packed red blood cells. 2. Place the client on 2 liters of oxygen per nasal cannula. 3. Insert a 19-gauge intravenous catheter. 4. Place the client on a cardiac monitor.

1) INCORRECT— This is an appropriate action, but there is another action that is a higher priority. The nurse will first attend to the client's immediate airway, breathing and circulatory needs (ABCs). The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work. 2) CORRECT — This hemoglobin level is critically low, which indicates less circulating oxygen. It is important to be certain that the available hemoglobin is well-oxygenated. The nurse first will apply oxygen to the client to address the oxygenation needs. The normal hemoglobin for men is 13 to 18 g/dL (130 to 180 g/L), and for women it is 12 to 16 g/dL (120 to 160 g/L). 3) INCORRECT— This is an appropriate action, but there is another action that is a higher priority. The nurse will first attend to the client's ABCs. The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work. 4) INCORRECT— This is an appropriate action, due to the risk of cardiac dysrhythmia secondary to tissue hypoxia. However, there is another action that is a higher priority. The nurse will first attend to the client's ABCs. The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work.