SLP-Med Surg- 100
A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client?
Ascending weakness The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Localized seizures are not a characteristic of Guillain-Barré syndrome. Skin desquamation is not a characteristic of Guillain-Barré syndrome. Deep tendon reflexes are absent with Guillain-Barré syndrome.
A client is admitted with renal calculi. Which clinical manifestations does a nurse expect the client to report?
Blood in the urine Frequency and urgency of urination Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain. Irritability may occur because of discomfort; twitching does not occur. Pyuria may occur when infection is present; skin problems do not occur. Pain radiates from the flank to the groin area.
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse most likely observe written in the client's medical record?
Cystitis Cystitis is an inflammation of the bladder that causes frequency and urgency of urination, pain on micturition, and hematuria. Chronic glomerulonephritis is a disease of the kidney that is associated with manifestations of systemic circulatory overload. Nephrotic syndrome is a condition of increased glomerular permeability characterized by severe proteinuria. Pyelonephritis is a diffuse, pyogenic infection of the pelvis and parenchyma of the kidney that causes flank pain, chills, fever, and weakness.
A nurse is caring for a client with hypothyroidism. Which clinical manifestations should the nurse anticipate when assessing this client?
Dry skin Brittle hair Dry skin results from a decrease in the metabolic rate, which is associated with hypothyroidism. Dry, brittle hair results from a decrease in the metabolic rate, which is associated with hypothyroidism. Weight loss is associated with hyperthyroidism because of an increase in body metabolism. Resting tremors are not associated with hypothyroidism; they are associated with Parkinson's disease. Heat intolerance is associated with hyperthyroidism, not hypothyroidism, because of the increase in body metabolism.
A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit?
Fractures Osteomalacia Eye calcium deposits Because of calcium loss from the bone, fractures, osteomalacia, and eye calcium deposits occur. Acidosis decreases calcium that binds to albumin, resulting in more ionized calcium (free calcium) in the blood. Lethargy and weakness are associated with hypercalcemia.
A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical?
Muscle rigidity Blank facial expression With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (CVA). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.
During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action?
Palpate the suprapubic area of the abdomen. Assessment is the priority; the nurse should determine whether clinical manifestations are caused by a full bladder. Teaching self-catheterization may be necessary eventually, but it is not the initial action. Ensuring an increase in fluid intake may be done to reduce urinary bacterial count and stone formation, but it is not the initial action. Initiating a regimen to monitor urinary output should be done, but it is not the initial action.
A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is prescribed. What is the nurse's explanation for the necessity of this diet?
reduce the amount of stool in the large bowel This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated. This diet does not promote peristalsis; the products of digestion remain in the intestine longer, and flatus is increased. Although a low-residue diet is less irritating, this is not the primary reason for its use before surgery. Antimicrobials such as neomycin are given to lower the bacterial count in the gastrointestinal tract.
A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients?
Difficulty swallowing Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.
A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional assessment should be made during every visit?
Evidence of urinary tract infection Presence of hyperemesis gravidarum Pregnant clients with sickle cell anemia are particularly vulnerable to infections, especially of the genitourinary tract; urine specimens should be examined frequently. A client with sickle cell anemia should always be monitored for hydration, so assessment for dehydration from vomiting caused by hyperemesis gravidarum is of high concern. Hypothyroidism affects 1 in 1500 women during pregnancy; women with sickle cell anemia are not at any higher risk for hypothyroidism than the general population. Women with sickle cell anemia are not at an increased risk for carpal tunnel syndrome during pregnancy.
A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching?
Fatigue Progressive wt gain Dry skin Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.
Which clinical indicators does the nurse identify that suggest a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? .
Frequent voidings Suprapubic distention With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and just enough urine is eliminated to relieve the pressure and the urge to void. The cycle is repeated as pressure again builds. Thus small amounts are voided without emptying the bladder. As urine is retained and the bladder enlarges, it causes suprapubic distention. Edema is a sign of fluid volume excess, not urinary retention. Oliguria (urinary output less than 500 mL/day) is a sign of kidney failure. Continual incontinence does not occur with urinary retention.
A 15-year-old adolescent who has type 1 diabetes mellitus is admitted to the pediatric intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL (9.4 mmol/L). The adolescent has a history of fluctuating blood glucose readings and difficulty adhering to the therapeutic regimen. A continuous insulin infusion is started. What adverse reaction to the infusion is most important for the nurse to monitor?
Hypokalemia Insulin moves potassium into the cells along with glucose, thus lowering the serum potassium level. Insulin does not lead to a reduced blood volume. Insulin does not directly alter the sodium levels. Insulin does not affect the calcium levels.
The laboratory report of a school-aged child with celiac disease reveals that the child has anemia. What does the nurse suspect as the most likely causes of the anemia?
Incomplete absorption of iron Incomplete absorption of folic acid Because mucosal lesions limit nutrient absorption there is inadequate iron and folic acid for hemoglobin synthesis, resulting in anemia. Lack of gluten in the diet is not the cause of the anemia. The anemia is caused by inadequate absorption rather than the quantity consumed. Lack of the intrinsic factor causes pernicious anemia, not the anemia associated with celiac disease.
What is the effect of parathyroid hormone on bones?
Increased bone breakdown Increased net release of calcium and phosphorus Increased serum calcium levels Parathyroid hormone increases bone breakdown, which increases serum calcium levels. Parathyroid hormone increases net release of calcium and phosphorus from bone into the extracellular fluid. It increases sodium and phosphorus excretion by the kidneys, not in the bone and increases absorption of calcium and phosphorus in the gastrointestinal tract by using activated vitamin D. However, this increased absorption of calcium and phosphorus is not related to the bone.
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest?
Increased muscular weakness Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.
The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?
Increased total iron-binding capacity (TIBC) TIBC may be elevated from 350 to 500 mcg/dL (82 µmol/L) (expected range is 250 to 460 mcg/dL [45-82 mcmol/L]) because the RBCs are compensating for the iron deficiency. The RBCs are microcytic, not macrocytic, because of their low iron content. A low platelet count is not associated with iron deficiency anemia. Decreased folate levels often are noted in vitamin B 12 anemias, such as occur with sprue and celiac diseases, as well as in folate deficiency anemia, but not in iron deficiency anemia.
Which instructions will be most beneficial for a diabetic client with renal disease?
Instruct the client to check blood pressure regularly Contact the primary healthcare provider before taking ibuprofen Encourage the client to undergo a microalbuminuria test yearly High blood pressure affects normal kidney function. Clients with renal disease must monitor blood pressure, because increased blood pressure can damage the vessel walls of the kidneys, thereby causing kidney damage, leading to kidney failure. Thus clients with renal disease should be encouraged to check their blood pressure regularly. Drugs such as ibuprofen are potent nephrotoxic agents; therefore, the client must be advised to contact the primary healthcare provider before ingestion to avoid further complications. Diabetic clients should undertake a microalbuminuria test yearly to determine the risk of developing end-stage kidney disease. Drinking boiled water may reduce the risk of infections; however, this instruction is less beneficial when compared to the other interventions. Going for a walk will improve the overall health of the client, but it is not a specific intervention that improves kidney function.
A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed?
It will compensate for both insensible and expected output over the next 24 hours. Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.
The nurse is providing care to a client who has had a transurethral resection of the prostate (TURP). Which goal is the priority?
Maintain patency of the indwelling catheter. Indwelling catheter patency promotes bladder decompression, which prevents distention and bleeding; continuous flow of an irrigant limits clot formation and promotes hemostasis. Maintaining patency of the cystostomy tube is not associated with a TURP; a cystostomy tube is a catheter that is placed directly into the bladder through a suprapubic incision. No abdominal incision is made because the resection is performed via the urethra. Although hemorrhage and infection may occur, no wound is observed because the surgery was performed via the urethra.
A primary healthcare provider schedules a bone scan for a client with osteoporosis. Which nursing actions are beneficial for the client?
Placing the client in the supine position Instructing the client to empty the bladder before the scan A bone scan is done to assess osteomyelitis, osteoporosis, primary and metastatic malignant lesions of bone, and certain fractures. The nurse has to place that client in the supine position for one hour for easy assessment while performing the bone scan. The nurse should instruct the client to empty the bladder before scanning. The client undergoing a computed tomography (CT) scan must be screened for a shellfish allergy to reduce the incidences of anaphylactic shock associated with the radiocontrast agent. Radio waves and a magnetic field are used during magnetic resonance imaging (MRI); therefore, the nurse should ensure that the client has no metal on the clothing before the procedure. The main risk of a myelogram is a spinal headache that usually resolves within 2 days of the procedure.
The nursing is caring for four different clients with eye disorders. Which client should be assessed for asthma before prescribing beta-adrenergic blockers?
Reduced outflow of acqueous humor and increased intraocular pressure causes glaucoma, which can be treated with different types of drugs. Before prescribing beta-adrenergic blockers, the client should be assessed for moderate to severe asthma because if these drugs are absorbed systematically, they constrict pulmonary smooth muscle and narrow airways. Increased lens density and reduced visual sensory perception indicates cataracts that can be treated only with cataract surgery. Increased tear secretion and blood shot eye appearance is observed in a client with conjuctivitis; this can be treated with ophthalmic antibiotics. Degeneration of corneal tissue indicates keratoconus, which can be cured by performing a surgery called keratoplasty (corneal transplant).
A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?
Respiratory and urinary Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.
A registered nurse is teaching a nursing student about a ketogenic diet. Which statements made by a nursing student indicates effective learning?
"The diet is recommended for obese clients." "Rapid weight loss is observed in clients utilizing this diet. A ketogenic diet is designed to provide enough protein to minimize the loss of lean body mass during weight loss. This diet is recommended for obese clients. Clients using a ketogenic diet benefit from relatively rapid weight loss and anorexia induced by ketosis. This diet consists of 1.5 to 2.5 g of protein per kilogram. Complications such as hypokalemia and orthostatic hypotension are observed in clients following this diet. Long-term outcomes of using this diet have not been established.
Which nursing intervention is most appropriate for a client in skeletal traction?
Assess the pin sites at least every shift and as needed Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.
A client who has had a transurethral resection of the prostate (TURP) experiences dribbling after the indwelling catheter is removed. Which is an appropriate nursing response?
"Increase your fluid intake and urinate at regular intervals." The response "Increase your fluid intake and urinate at regular intervals" will improve bladder tone, which should alleviate dribbling. The response "I know you're worried, but it will go away in a few days" identifies feelings but does not actively help the client solve the problem. Limiting fluid intake and urinating at the urge do not increase bladder tone; fluids should be increased and the time between voidings should be increased gradually. Continuous bladder decompression from a catheter will reduce bladder tone; bladder tone will improve after the indwelling catheter is removed.
A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction?
"Seek early treatment for respiratory infections." A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis. The alkalinity of bubble baths is linked to urinary tract infections, not glomerulonephritis. Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection.
A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine?
Calcium: 7.6 mg/dL (1.9 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L) A client with acute kidney injury will have a low calcium level, a high potassium level, and an elevated creatinine level.
A client has a total hysterectomy with bilateral salpingo-oophorectomy for cancer of the ovary. In addition to encouraging ambulation, what exercise should the nurse instruct the client to perform to help prevent postoperative deep vein thrombosis (DVT)?
Ankle pumping is the most effective of the four exercises presented to prevent DVT. It requires contraction and relaxation of the tibialis anterior muscles, the gastrocnemius muscles, and the soleus muscles as the client alternates dorsal and plantar flexion. These movements cause contraction of the skeletal muscles, which exerts pressure on the veins to facilitate venous return. The other options represent desirable exercises in preventing DVT; however, they are not as effective as ankle pumps
A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify?
Anorexia Limb pain Splenomegaly Hypermetabolism associated with the leukemic process results in loss of appetite. Bone marrow dysfunction and invasion of the periosteum result in bone pain. Infiltration, enlargement, and fibrosis of the spleen occur early in the disease process as the excess white blood cells are trapped. Flushing is not expected. Bone marrow dysfunction results in anemia, and pallor accompanies the decreased erythrocyte count. Mouth lesions (stomatitis) occur later during the disease process or as a result of chemotherapy.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant?
instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.
Dysmenorrhea is suspected in a client with symptoms including backache, diarrhea, syncope, and headache. After reviewing the data, the primary healthcare provider decides not to prescribe diclofenac. Which of these statements made by the client support this decision?
"I have a history of bleeding ulcers." "I am allergic to aspirin." "I have a history of deep vein thrombosis." Backache, diarrhea, syncope, and headache are symptoms of dysmenorrhea. A nonsteroidal antiinflammatory drug, such as diclofenac, is the primarily prescribed drug, but it should not be given to a client who is allergic to aspirin. The drug is also contraindicated in clients with a history of bleeding ulcers. Because anticoagulants may be prescribed to the client with deep vein thrombosis, diclofenac use is contraindicated in a client with such a history. Penicillin allergy may not contraindicate the use of diclofenac. Renal calculi also may not contraindicate the use of diclofenac. Therefore a client with a history of renal calculi can likely be safely prescribed diclofenac for dysmenorrhea.
Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment?
A raised toilet seat A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.
Why does the nurse encourage continued healthcare supervision for a pregnant woman with pyelonephritis?
Antibiotic therapy should be administered until the urine is negative. Healthcare supervision requires treatment with an appropriate antibiotic until two cultures of urine are negative; recurring pyelonephritis often leads to preterm birth. Preeclampsia is not preceded by specific infections. Pelvic inflammatory disease is associated with infections of the genital, not the urinary, tract. A low-protein diet inhibits fetal development and is contraindicated during pregnancy.
What client response indicates to the nurse that a vasodilator medication is effective?
Blood pressure changes from 154/90 to 126/72 mm Hg Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.
The nurse is caring for a client with fat embolism syndrome (FES). Which anatomical part of the bone depicted in the figure is responsible for the client's condition?
Choice B depicts spongy cancellous tissue. Softer cancellous tissue contains large spaces or trabeculae, which are filled with red and yellow marrow. Yellow marrow contains fat cells that may be dislodged and enter the bloodstream, which can cause FES. Choice A indicates articular cartilage, which is a smooth white tissue that covers the ends of bones. Choice C indicates compact bone, which is hard due to inorganic calcium salt deposits. Choice D depicts bone cells (osteocytes) present in the deepest layer of the periosteum.
A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response?
Degeneration of the neurons of the basal ganglia Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure?
Dependent edema RUQ discomfort Swollen hands and fingers With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
A client with a history of chronic kidney disease is hospitalized. Which assessment findings will alert the nurse to kidney insufficiency?
Edema and pruritus The accumulation of metabolic wastes in the blood ( uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. Pallor, not flushing, occurs with chronic kidney disease as a result of anemia. Dribbling after voiding is a urinary pattern that is not caused by chronic kidney disease; this may occur with prostate problems. Diminished force and caliber of stream occur with an enlarged prostate, not kidney disease.
Which metabolic manifestations are likely to be observed in a client with hypothyroidism?
Intolerance to cold Decreased body temperature Cold intolerance and decreased body temperature are the metabolic manifestations observed in a client with hypothyroidism. Impaired memory is the neuromuscular manifestation of hypothyroidism. Difficulty in breathing is the pulmonary manifestation observed in the client with hypothyroidism. Decreased blood pressure is the cardiovascular manifestation observed in the client with hypothyroidism
The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client?
Monitoring the client's blood glucose levels Assessing if the client is under antiplatelet medication A client with cataracts has increased lens density due to drying and compression of older lens fibers. Clients with disease conditions such as diabetes mellitus may develop cataracts. Therefore the client's blood glucose levels should be assessed to determine the severity of the disease. Surgery is the only "cure" for cataracts. Before performing surgery, the client should be assessed for any conditions that may affect blood clotting, such as use of aspirin and clopidogrel. Phacoemulsification is the surgical procedure performed in a client with cataracts in which the lens is extracted. Keratoplasty is performed in a client with improper corneal shape. Pain and redness is not observed in age-related cataract. Both phacoemulsification and keratoplasty are surgical procedures and not nursing actions.
A nurse obtains the history of a client with early colon cancer. Which clinical finding does the nurse consider consistent with a diagnosis of cancer of the descending, rather than the ascending, colon?
Obstruction Signs and symptoms of obstruction occur earlier with cancer in the descending colon because the consistency of the stool is formed rather than liquid. Pain, a late symptom of colon cancer, may occur regardless of the location of the primary lesion. Fatigue occurs in colon cancer regardless of the primary site; it is related to anorexia, weight loss, and anemia. Bleeding, which results in anemia, occurs in colon cancer regardless of the primary site because the lesions extend into the intestinal mucosa.
Which condition is characterized by infection of a client's bone or bone marrow?
Osteomyelitis Osteomyelitis is infection of bone or bone marrow. Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency. Herniated disc is caused by structural damage of the intervertebral discs in which the nucleus pulposus seeps through a torn or stretched annulus. Spinal stenosis is narrowing of the spinal canal.
A client's laboratory report shows altered serum calcium concentration. Which hormones are responsible for this condition?
Parathyroid hormone Calcitonin Produced by the thyroid gland, calcitonin decreases the serum calcium concentration if it increases above the normal level. Parathyroid hormones increase and stimulate bones to promote osteoclastic activity and release calcium into the blood in response to low serum calcium levels. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to maintain the organic matrix of bone. Growth hormone helps to increase bone length and determine the amount of bone matrix formed before puberty.
Which diagnostic study is used to determine a client's bone density?
Standard X-ray A standard X-ray is used to determine bone density. A diskogram is used to visualize abnormalities of the intervertebral disc. A computed tomography scan is used to identify soft tissues, bony abnormalities, and various types of musculoskeletal trauma. Magnetic resonance imaging is used to diagnose avascular necrosis, disc disease, tumors, osteomyelitis, ligament tears, and cartilage tears.
A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she says to a nurse at the clinic, "I don't feel well." The nurse reviews the medical record. Based on this information, what does the nurse conclude is the client's priority need?
Preventing infection The prevention of infection is the priority because an infection can be life threatening for a client who is immunocompromised. Chemotherapeutic medications depress the bone marrow, causing leukopenia. This client's white blood cell count is below the expected range of 4500 to 11,000/mm 3 (4.5 to 11 × 10 9/L) for an older female adult. Although the elevation in the client's temperature, pulse, and respirations may be related to the direct effects of the chemotherapeutic agents, they also may reflect that the client is resisting a microbiologic stress. Although a balance between rest and activity is important, it is not the priority. Although chemotherapeutic medications depress the bone marrow and cause anemia, this client's red blood cell count is within the expected range of 4.0 to 5.0 million/mm 3 (4.7 to 6.1 × 10 12/L) for an older female adult. The client's hemoglobin level is within the expected range of 11.5 to 16.0 g/dL (115 to 160 mmol/L). Even though preventing injury is important, it is not the priority. Although chemotherapeutic medications depress the bone marrow, causing thrombocytopenia, this client's platelet count is within the expected range of 150,000 to 400,000/mm 3 (150 × 10 9 /L to 400 × 10 9 /L) for an adult. Although maintaining fluid balance is important, it is not the priority. The client's hematocrit is within the expected range of 38% to 41% for an older female adult, indicating that the client is not dehydrated. The client's blood pressure is not decreased, which occurs with dehydration. Although chemotherapeutic medications may cause nausea, vomiting, and diarrhea, the client did not indicate that these occurred.
