130 test 4 nclex questions

A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? A.Systolic murmur B.Alopecia C.Weight gain D.No joint swelling

B. Because of inflammation throughout the body, hair loss is expected A. Cardiac friction rub is an expected finding C. Weight loss, not gain is an expected finding D. 90% of patients with SLE experience joint issues

A patient is in the hospital for the treatment of Peptic Ulcer Disease. The nurse finds the patient vomiting and complaint of a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect the symptoms indicate? A. The treatment for the Peptic ulcer is ineffective​ B. A reaction to the medication given for the ulcer​ C. Gastric Penetration​ D. Perforation of the Peptic Ulcer ​

D. Perforation of the peptic ulcer Rationale: Signs and symptoms of perforation include the following: Sudden, severe upper abdominal pain (persisting and increasing in intensity), which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock.

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to peptic ulcer disease. Which of the following findings should the nurse expect?​ A. Rigid abdomen​ B. Tachycardia​ C. Elevated Blood Pressure​ D. Circumoral Cyanosis​ E. Rebound Tenderness

A. Rigid Abdomen​ B. Tachycardia Rationale: Manifestations of a perforation include a rigid board-like abdomen and tachycardia due to gastrointestinal bleeding that accompanies a perforation.

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie-dense foods B. Drink canned protein supplements C. Increase intake of high fiber foods D. Take a bulk-forming laxative daily

B.Correct: A high-protein diet is recommended for the client who has Crohn's disease. Canned protein supplements are encouraged A.A high-protein diet is recommended for the client who has Crohn's disease C.A low-fiber diet is recommended for the client who has Crohn's disease to reduce inflammation D.Bulk-forming laxatives are recommended for the client who has diverticulitis

A nurse is caring for a client with SLE, who is experiencing an episode of Raynaud's phenomenon . Which of the following findings should the nurse expect with Raynaud's phenomenon? A.Pallor of toes with cold exposure B.No joint pain C.Butterfly rash D.Pink, warm skin

A. Raynaud's phenomenon is a form of arteriole vasoconstriction that results in coldness, pallor of the fingers or toes, and pain B. Joint pain is a finding in SLE, but not specific to Raynaud's phenomenon C. A butterfly rash is a finding in SLE, but not specific to Raynaud's phenomenon D. Skin within normal limits is not correct

Crohn's disease is a condition of malabsorption caused by which pathophysiological process? A. Inflammation of all layers of intestinal mucosa B. Infectious disease C. Disaccharidase deficiency D. Gastric resection

A.Inflammation of all layers of intestinal mucosa Crohn's disease is also known as regional enteritis and can occur anywhere along the gastrointestinal tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small-bowel bacterial overgrowth, leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.

¨A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply.) a. Recent influenza b. Decreased range of motion c. Hypersalivation d. Increased blood pressure e. Pain at rest

ANSWER = A, B, & E Recent Flu is considered an exacerbated factor and are indicative in clients who have RA

¨A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) a. Urinalysis b. Erythrocyte sedimentation rate (ESR) c. BUN d. Antinuclear antibody (ANA) titer e. WBC count

ANSWER = B, D, & E ESR is a lab test used to dx RA. The test will show an elevated result in clients who have RA ANA Titer is a lab test used to dx RA and will show positive in clients who have RA WBC Count will show a decreased results in clients who have RA

Which is often the most disabling clinical manifestation of multiple sclerosis? A. Fatigue B. Spasticity C. Ataxia D. Pain

Answer: A Fatigue affects 87% of people with MS, and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are other clinical manifestations of MS, but are not the most disabling.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: A rest in an air-conditioned room B. increase the dose of muscle relaxants C. take a hot bath D. avoid naps during the day

Answer: A }Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis? a.A demanding and stressful job b.Changing to a modified vegetarian diet c.Beginning a weight- training program d.Walking 2 miles everyday

Answer: A. A demanding and stressful job Rationale: Stressful and emotional events have been linked to exacerbation of ulcerative colitis.

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A. A disorder in which the body has too many immunoglobulins B. A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" C. A disorder in which histocompatible cells attack the immunoglobulins D. A disorder in which the body does not have enough immunoglobulins

Answer: B Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A.Fluctuations in blood pressure B.Loss of cognitive function C.Ineffective cough D.Drooping eye lids

Answer: B Loss of cognitive function is a manifestation associated with MS. Fluctuation in BP is a manifestation associated with amyotrophic lateral sclerosis. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. Drooping eye lids is associated with myasthenia gravies

A nurse caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? a."You need to conserve energy at this time." b."Lying quietly in bed helps slow down the activity in your intestines." c."Staying in bed promotes the rest and comfort you need." d."Staying in bed will help prevent injury and minimize your fall risk."

Answer: B. "Lying quietly in bed helps slow down the activity in your intestines." Rationale: The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.

A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? a.Raw vegetable salad with low-fat dressing b. Roast chicken and white rice c.Fresh fruit salad and milk d. Peanut butter on whole wheat bread

Answer: B. Roast chicken and white rice. Rationale: Clients who have ulcerative colitis are restricted to a low-fiber diet, which omits Whole grains and raw fruits and vegetables. Roast chicken with white rice is the best choice.

A client who has ulcerative colitis has persistent diarrhea and has lost 12 pounds since the exacerbation of the disease. Which of the following will be most effective in helping the client meet nutritional needs? a.Continuous enteral feedings b.Following a high- calorie, high protein diet c.Total parenteral nutrition (TPN) d.Eating six small meals a day

Answer: C. Total parenteral nutrition (TPN) Rationale: Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN.

A nurse is beginning a physical assessment of a client who has a new dx of MS. Which of the following findings should the nurse expect? (Select all that apply) A. Areas of paresthesia B. Involuntary Eye Movements C. Alopecia D. Increased salivation E. Ataxia

Answers: A,B,E loss of skin sensation, nystagmus, and ataxia all occur in patients with MS

A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory tests should the nurse expect to be elevated. (Select all that apply) A.Hematocrit B.Erythrocyte sedimentation rate C.WBC D.Folic acid E.Albumin

B is correct - increased erythrocyte sedimentation rate is a finding in a client who has Crohn's disease as a result of inflammation C is correct - increased WBC is a finding in a client who has Crohn's disease A is not correct - hematocrit is decreased as a result of chronic blood loss D is not correct - a decrease in folic acid level is indicative of malabsorption due to Crohn's disease E is not correct - a decrease in serum albumin is indicative of malabsorption due to Crohn's disease

A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist? A. Barium study of the upper gastrointestinal tract ​​B. Endoscopy ​​C. Gastric secretion study ​​D. Stool antigen test

B. Endoscopy Rationale: Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. Less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test.

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:​​ A. "I should stop all my medications if I develop any side effects."​​ B. "I should continue my treatment regimen as long as I have pain."​​ C. "I have learned some relaxation strategies that decrease my stress."​​ D. "I can buy whatever antacids are on sale because they all have the same effect."

C - "I have learned some relaxation strategies that decrease my stress" Rationale: The nurse assists the client to identify stressful or exhausting situations. A hectic lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings along with the regular administration of medications. The client may benefit from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, behavior modification, massage, or acupuncture may be helpful.

•You're providing a community in-service about gastrointestinal disorders. During your teaching about cholecystitis, you discuss how cholelithiasis can lead to this condition. What are the risk factors for cholelithiasis that you will include in your teaching to the participants? Select all that apply:* • A. Being male • B. Underweight • C. Being female • D. Older age • E. Native American • F. Caucasian • G. Pregnant • H. Family History • I. Obesity

C, D, E, G, H and I. Cholelithiasis is the formation of gallstones. Risk factors include: being female, older age (over 40), Native American or Mexican American descent, pregnant, obesity, and family history.

Which of the following statements by the client indicates an understanding of teaching about self care from a patient with SLE? A."I can go in a tanning bed; I will just go 3 times a week" B."I will apply powder to skin rashes" C."I should use a mild hair shampoo" D."I will inspect my skin twice a month for rashes"

C. A client should use a mild shampoo that does not irritate the scalp. A. Clients should AVOID prolonged exposure to UV radiation B. Creams, not powder are used for rashes D. Skin should be inspected daily

A nurse is preparing plan of care for a client who has SLE. The client complains of fatigue, joint tenderness, swelling and difficulty urinating. Which lab findings should the nurse expect? A.Increased hemoglobin B.Increased serum C3 and C4 C.Elevated BUN D.Negative ANA titer

C. Elevated BUN is expected finding due to kidney injury in a client who has SLE. A. Pancytopenia, not elevated hemoglobin is a common finding B. Serum compliment C3 and C4 is decreased in a patient with SLE D. ANA titer would be positive because SLE is an autoimmune disorder

The nurse is reviewing the laboratory results of a client with Crohn's disease. Which of the following would the nurse most likely find? A. Decreased white blood cell count B. Increased albumin levels C. Stool cultures negative for microorganisms or parasite D. Decrease erythrocyte sedimentation rate

C.Stool cultures negative for microorganisms or parasite Stool cultures fail to reveal an etiologic microorganism or parasite, but occult blood and occult blood and white blood cells (WBCs often are found in the stool. Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies. The WBC count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder. Serum protein and albumin levels may be low because of malnutrition.

A patient in the emergency room has signs and symptoms associated with cholecystitis. What testing do you anticipate the physician will order to help diagnose cholecystitis? Select all that apply: •A. Lower GI series •B. Abdominal ultrasound •C. HIDA Scan (Hepatobiliary Iminodiacetic AciD scan) •D. Colonoscopy

The answers are B and C. These two tests can assess for cholecystitis. A lower GI series would not assess the gallbladder but the lower portions of the GI system like the rectum and large intestine. Option D is wrong because it would also assess the lower portions of the GI system.

•Your patient is diagnosed with acute cholecystitis. The patient is extremely nauseous. A nasogastric tube is inserted with GI decompression. The patient reports a pain rating of 9 on 1-10 scale and states the pain radiates to the shoulder blade. Select all the appropriate nursing interventions for the patient: •A. Encourage the patient to consume clear liquids. •B. Administered IV fluids per MD order. •C. Provide mouth care routinely. •D. Keep the patient NPO. •E. Administer analgesic as ordered. •F. Maintain low intermittent suction to NG tube.

The answers are B, C, D, E, and F. The treatment for cholecystitis includes managing pain, managing nausea/vomiting (a NG tube with GI decompression (removal of stomach contents) to low intermittent suction may be ordered to help severe cases), keep patient NPO until signs and symptoms subside, mouth care from vomiting and nasogastric tube, and administer IV fluids to keep the patient hydrated.

¨A patient with severe rheumatoid arthritis is scheduled for a procedure called an arthrodesis. The nursing student you are precepting asks you to describe the procedure. Your response is: a. "It is a procedure where the affected joint is removed and each end of the bones found within that joint are fused together." b. "It is a procedure that involves replacing the joint with an artificial one." d. "It is a procedure where the surgeon goes in with a scope and cleans out the affected joint." e. "It is a procedure where the synovium is completely removed within the joint, which helps decrease inflammation of the joint.

¨ANSWER = A. Arthrodesis "...is a procedure where the affected joint is removed and each end of the bones found within that joint are fused together." ¨B. described a joint replacement ¨C. described a procedure called a "surgical cleaning" ¨D. described a procedure called a Synovectomy

¨A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. What should the nurse be sure to include in the teaching? a. You can experience weight gain b. You can experience abdominal pain c. You can experience stiffness in the morning d. You can experience low blood sugar

¨ANSWER = C ¨Those with RA should expect joint stiffness in the morning and upon rising after long periods of rest. This is a common side effect of the disease.

•A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis? •A. Brownie with nuts •B. Bowl of mixed fruit •C. Grilled turkey •D. Baked potato

•A CORRECT: Foods that are high in fat, such as a brownie with nuts, can cause cholecystitis. •B. Fruits are low in fat and not associated with cholecystitis. •C. Turkey is low in fat and not associated with cholecystitis. •D. Baked potatoes are low in fat and not associated with cholecystitis.