prepu exam 3 practice

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia

Facial paralysis

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? Maintain the client in a semi-Fowler's position. Administer enteral or parenteral nutrition. Carry out wound care as prescribed. Withhold oral feedings

Maintain the client in a semi-Fowler's position.

A client with a lengthy history of alcohol addiction is being seen for jaundice. What does the appearance of jaundice most likely indicate? liver disorder gallbladder disease bile overproduction glucose underproduction

liver disorder

Cardiac effects of hyperthyroidism include decreased pulse pressure. decreased systolic blood pressure. bradycardia. palpitations.

palpitations

A client with a lengthy history of alcohol addiction is diagnosed with cirrhosis. The nurse emphasizes that the principal goal of cirrhosis therapy is: preserving liver function. curing the illness. restoring fat-soluble vitamin absorption. increasing alcohol tolerance.

preserving liver function.

The nurse is caring for a client who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? Select all that apply. Measure urine output every 8 hours. Assess and document vital signs every 4 hours. Measure abdominal girth daily. Perform daily weights. Monitor number of bowel movements per day.

Measure urine output every 8 hours. Measure abdominal girth daily. Perform daily weights.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? "How did this happen? I've been faithful my entire marriage." "I'll be very careful when preparing food for my family." "I'll wash my hands often." "I'll take all my medications as ordered."

"How did this happen? I've been faithful my entire marriage."

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity Ingestion of undercooked beef

-Infection at school -Suboptimal sanitary habits -Consumption of sewage-contaminated water or shellfish -Sexual activity

A nurse is performing health education with the family member of a patient who has ascites. The nurse should be cognizant of which physiologic processes that cause ascites? Select all that apply. Sodium and water retention A damaged liver Insufficient renal flow Increased lymphatic flow Decreased synthesis of immunoglobulin G

-Sodium and water retention -A damaged liver -Increased lymphatic flow

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? "You could have gotten it by using I.V. drugs." "You must have received an infected blood transfusion." "You probably got it by engaging in unprotected sex." "You may have eaten contaminated restaurant food."

"You may have eaten contaminated restaurant food."

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement? "The head of your bed must remain flat for 24 hours after surgery." "You should avoid deep breathing and coughing after surgery." "You won't be able to swallow for the first day or two." "You must avoid hyperextending your neck after surgery."

"You must avoid hyperextending your neck after surgery."

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? Infusing IV fluids rapidly as ordered Encouraging increased oral intake Restricting fluids Administering glucose-containing I.V. fluids as ordered

Restricting fluids

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? Hepatic encephalopathy Esophageal varices Hepatitis C Portal hypertension

Hepatic encephalopathy

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by: Edema and inflammation Pleural effusion Sepsis Disseminated intravascular coagulopathy

Edema and inflammation

A client with severe acute pancreatitis has been on nothing by mouth status for two days. Which nutrition will the nurse expect to be prescribed for this client? Clear liquids Enteral feedings Diet as tolerated Parenteral nutrition

Enteral feedings

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Nebulizer and thermometer Intubation tray and suction apparatus Blood pressure apparatus Incentive spirometer

Intubation tray and suction apparatus

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do? Monitor laboratory values daily for elevated thyroid-stimulating hormone. Observe for swelling of the neck, tracheal deviation, and severe pain. Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Take small meals of soft consistency Increase the intake of calcium and proteins. Include additional servings of fruits and raw vegetables Include fish, liver, and chicken in diet

Take small meals of soft consistency

The most accurate indicator of fluid loss or gain in an acutely ill client is: blood pressure. weight. pulse rate. edema.

weight

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering? Calcium gluconate Potassium chloride Sodium bicarbonate Sodium phosphorus

Calcium gluconate

In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? Acetylcholine Epinephrine Norepinephrine Dopamine

Acetylcholine

What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? Come to the clinic for IV fluid therapy daily. Limit the fluid intake at night. Consume adequate amounts of fluid. Weigh daily.

Consume adequate amounts of fluid

The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? Temperature and oxygen saturation Heart rate and blood pressure Breath sounds and bowel sounds Color, warmth, movement, and sensation of extremities

Heart rate and blood pressure

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? MS is a progressive demyelinating disease of the nervous system. MS usually occurs more frequently in men. MS typically has an acute onset. MS is sometimes caused by a bacterial infection.

MS is a progressive demyelinating disease of the nervous system

Which intervention is the most critical for a client with myxedema coma? Administering an oral dose of levothyroxine (Synthroid) Warming the client with a warming blanket Measuring and recording accurate intake and output Maintaining a patent airway

Maintaining a patent airway

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? Anxiety Powerlessness Ineffective denial Risk for disuse syndrome

Powerlessness

A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? Side-lying with one pillow under the head Head of the bed elevated 30 degrees and no pillows placed under the head Semi-Fowler with the head supported on two pillows Supine, with a small roll supporting the neck

Semi-Fowler with the head supported on two pillows

The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? Severe abdominal pain Fever Jaundice Mental agitation

Severe abdominal pain

A client with severe abdominal pain and an abnormal computed tomography (CT) scan, which shows an enlarged pancreas, has been andmitted to a medical unit today. The nurse anticipates including which actions in the client's plan of care? Select all that apply. Use a pain scale throughout treatment. Provide oral hygiene and gargling solutions. Administer pain relief measures. Assess current nutrtional status. Encourage ambulation as tolerated. Mantain nothing by mouth (NPO) diet.

Use a pain scale throughout treatment. Administer pain relief measures. Mantain nothing by mouth (NPO) diet.

A client telephones the medical clinic to ask for help with pruritus and a change in stool color. Which additional symptom(s) indicates to the nurse that the client is experiencing gallbladder stones? Select all that apply. Diarrhea Yellow sclera Epigastric pain Dark-colored urine Right shoulder pain

Yellow sclera Dark-colored urine Right shoulder pain

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? Ammonia Calcium Bicarbonate Alcohol

ammonia

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications? metabolism of medications need for increased drug dosages need for more frequently divided doses medications becoming ineffective in clients with liver disease

metabolism of medications

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply. Administer pain-relieving medication Administer a low-fat diet Administer electrolytes Administer plasma Assist the client to a semi-Fowler position

-Administer pain-relieving medication -Administer electrolytes -Administer plasma -Assist the client to a semi-Fowler position

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? Jaundice Pruritus of the arms and legs Fatigue during ambulation Irritability and drowsiness

Irritability and drowsiness

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? Maintains effective respirations and airway clearance Shows increasing mobility Receives adequate nutrition and hydration Demonstrates recovery of speech

Maintains effective respirations and airway clearance

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: thyroid storm. cretinism. myxedema coma. Hashimoto's thyroiditis.

myxedema coma