Basic Care and Comfort and Adaptation

An adolescent who abuses opiates wishes to stop but is unable to do so. What is the most appropriate intervention? Gastric lavage Rehabilitation Naloxone administration Activated charcoal administration

2

A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Drying of hair Drying of surface cells Decreased synthesis of vitamin D Decreased efficiency to cool the body Decreased excretion of waste products through the skin

2, 4, and 5

The nurse is caring for a client who had a thyroidectomy. Which symptoms will the client exhibit if having a thyrotoxic crisis? An increased pulse deficit A decreased blood pressure A decreased heart rate and respirations An increased temperature and pulse rate

4. Thyrotoxic crisis is severe hyperthyroidism; excessive amounts of thyroxine increase the metabolic rate, thereby raising the pulse and temperature. During crisis there usually is no increase in the difference between the apical and the peripheral pulse rates (pulse deficit). The blood pressure will increase to meet the oxygen demand caused by the increased metabolic rate during crisis. Because of the increased metabolic rate, the pulse and respiratory rates increase to meet the body's oxygen needs.

After the removal of a hydatidiform mole, the nurse assesses the client's laboratory data during a follow-up visit. The nurse notes that a prolonged increase of the serum human chorionic gonadotropin (hCG) level is a danger sign. Which condition is this client at increased risk of developing? Uterine rupture Choriocarcinoma Hyperemesis gravidarum Disseminated intravascular coagulation (DIC)

2

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? Binder Ice bag Elastic bandage Warm compress

2.

Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits what sign? Expiratory grunting Substernal retractions Tachycardia of 160 beats/min Respirations of 50 to 60 breaths/min

2. Substernal retractions are a prominent feature of respiratory problems in preterm infants because of their compliant chest walls. Expiratory grunting is more indicative of low body temperature, not respiratory distress, in a preterm infant. Tachycardia of 160 beats/min is within the expected range of 110 to 160 beats/min. A rapid respiratory rate of 40 to 60 breaths/min is expected in neonates.

Which statements are true regarding chondrosarcoma? . Chondrosarcoma can arise from benign bone tumors. Chondrosarcoma develops in the medullary cavity of long bones. Chondrosarcoma is mostly treated by radiation and chemotherapy. Chondrosarcoma occurs mostly in young males between ages 10 and 25 years. Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.

1 and 5. Chondrosarcoma is a malignant type of bone tumor that can arise from benign bone tumors. Chrondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones. Ewing's sarcoma develops in the medullary cavity of long bones. Chondrosarcoma is mostly treated by wide surgical resection. Chondrosarcoma occurs mostly in older adults between ages 50 and 70 years.

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? . Dark urine Yellow skin Pain on urination Clay-colored stool Coffee-ground vomitus

1, 2,, and 4. When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color. Jaundice (bile pigments causing yellow skin, sclera, and mucous membranes) results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood; the bilirubin is carried to all body regions. The stools are clay-colored, not brown, because the bile pigments are not present in the gastrointestinal (GI) tract as a result of the obstruction of the common bile duct. Pain is experienced in the right upper quadrant, not on urination, because of spasm of the gallbladder, whether or not there is biliary obstruction. Coffee-ground vomitus indicates gastric bleeding; it is not a unique sign of cholelithiasis with obstructive jaundice.

A nurse who is caring for a 7-year-old child with acute glomerulonephritis assesses the child for cerebral complications. What signs and symptoms indicate cerebral involvement? Headache, drowsiness, and vomiting Generalized edema, anorexia, and restlessness Anuria, temperature higher than 103° F (39.4° C), and confusion Cardiac decompensation, heart rate of 114 beats/min, and vomiting

1. Headache, drowsiness, and vomiting may occur if the blood pressure remains increased and leads to cerebral edema. Drowsiness, not restlessness, will occur; generalized edema and anorexia are not specific to cerebral edema. Although fever and confusion may occur, anuria is not specific to cerebral edema. Although the pulse may be altered and vomiting may occur, cardiac decompensation is not related to cerebral involvement.

A nurse is teaching the parents of a malnourished 6-year-old child with celiac disease about foods and nutrients that will help correct a problem related to celiac disease. Which foods and nutrients should the nurse recommend for this child? High-calorie foods rich in protein and fat to correct weight loss Foods high in folic acid, iron, and vitamin B 12 to correct anemia Supplements of vitamins A, D, E, and K to correct coagulation deficiencies Foods high in potassium and magnesium to correct bone growth deficiencies

2. Children with celiac disease are anemic. Foods high in folic acid, iron, and vitamin B 12 promote hemopoiesis. Fat is not adequately absorbed by children with celiac disease; therefore, a low-fat diet is indicated. Of these supplements, only vitamin K is related to blood coagulation. Celiac disease does not cause coagulation deficiencies. Potassium and magnesium are necessary elements that are lost during celiac crisis but are not related to bone growth.

A nurse is assessing an adolescent child with the diagnosis of hemophilia. In what part of the body does the nurse expect bleeding to occur? Brain Joints Intestines Pericardium

2. Joints are the most commonly involved areas because they are subject to weight-bearing and constant movement. Neither the brain, intestines, nor the pericardium is the most common site of bleeding in hemophilia.

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression? Calcium carbonate and vitamin D must be increased in the diet because of the effects of myelosuppression. Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. The development of myelosuppression explains why the client has nausea, vomiting, anorexia, and alopecia. Frequent testing for restlessness, muscle control, and pupillary response is necessary because the meninges may be irritable.

2. Myelosuppression involves a decreased number of red blood cells (anemia), resulting in a reduced oxygen-carrying capacity of the blood and fatigue. A decreased number of white blood cells (leukopenia) results in a potential for infection. A decreased number of platelets (thrombocytopenia) results in a potential for bleeding. Myelosuppression is not related directly to calcium carbonate and vitamin D; myelosuppression, a reduction in bone marrow activity, results in decreased numbers of red blood cells (RBCs), white blood cells (WBCs), and platelets. Myelosuppression is not related to nausea, vomiting, anorexia, or alopecia. Myelosuppression is related to bone marrow activity, not the nervous system.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? Loosening of the sutures Sharp increase in serosanguineous drainage Purplish color of the incision Protrusion of organs through an open incision

2. Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides, but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload? Contour Orthopneic Recumbent Trendelenburg

2. The client's paroxysmal dyspnea was probably caused by sleeping in bed with the legs at the level of the heart; the orthopneic position increases venous return from dependent body areas, increasing the intravascular volume. Sitting up and leaning forward while keeping the legs dependent slows venous return and increases thoracic capacity. Although the contour position elevates the client's head, it does not place the legs in a dependent enough position to substantially decrease venous return. The recumbent position is contraindicated. Venous return increases when the lower extremities are at the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity. The Trendelenburg position is contraindicated. Venous return increases when the lower extremities are higher than the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity.

A nurse is caring for a client with continuous bladder irrigation. Which action should the nurse take? Monitor urinary specific gravity to determine hydration. Subtract irrigant from output to determine urine volume. Record urinary output every hour to determine kidney function. Obtain a 24-hour urine specimen to determine urine concentration.

2. The total amount of irrigation solution instilled into the bladder is eliminated with urine and therefore must be subtracted from the total output to determine the volume of urine excreted. An accurate specific gravity cannot be obtained when irrigating solutions are instilled into the bladder. Hourly outputs are indicated only if there is concern about renal failure or oliguria. A 24-hour urine test is not accurate if the client is receiving continuous bladder irrigations.

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. The nurse is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? Weight every day Urinary output every hour Blood pressure every 15 minutes Extent of peripheral edema every 4 hours

2. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information that is useful for assessing fluid needs in a burn client. Daily weight reflects fluid retention or loss; however, other factors besides fluid affect weight in a burn client. Blood pressure results may indicate hypervolemia or hypovolemia; however, it is not as accurate an indicator of insufficient fluid replacement as is urinary output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

After an assessment, the nurse finds that the client has a partial loss of peripheral vision. The client's eye examination report shows an intraocular pressure of 24 mmHg. What does the nurse suspect is causing this condition? Reduced elasticity of the lens Unevenness in the cornea Excess production of aqueous humor Presence of nontransparent substance in the vitreous humor

3. Partial loss of peripheral vision and a high intraocular pressure of 24 mmHg (normal is 10 to 21 mmHg) are indicative of glaucoma. Glaucoma is typically caused by an excess production of aqueous humor. Reduced elasticity of the lens due to aging may result in loss of accommodation and presbyopia. Unevenness in the cornea may cause astigmatism. The presence of nontransparent substances in the vitreous humor may block light passing through the vitreous membrane and affect vision.

The parents of a school-aged child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse? "Radiation retards the growth of cells in the bone marrow of the cranium." "This therapy decreases cerebral edema and prevents increased intracranial pressure." "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." "Neoplastic drug therapy without radiation is effective in most cases, but this is a precautionary treatment."

4

A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction? "Restrict fluid intake." "Take showers instead of bubble baths." "Avoid situations that involve physical activity." "Seek early treatment for respiratory infections."

4. 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 3-year-old child is admitted to the pediatric unit with a hemoglobin level of 6.4 g/dL (64 mmol/L). What should the nurse's priority assessment be? Manifestations of shock Increased white cell count Presence of hemoglobinuria Signs of cardiac decompensation

4. Cardiac decompensation results because the heart attempts to maintain tissue oxygenation by increasing its workload. Shock occurs with hemorrhage because the body does not have time to adapt to the sudden loss of blood. With chronic anemia, compensatory mechanisms take over. An increased white blood cell count indicates infection; however, the data do not indicate the presence of an infection. Hemoglobin in the urine suggests hemolytic anemia. Although it is important to determine the cause of the anemia, this is not the priority.

A clinic nurse is interviewing a client with syphilis. The nurse should ask the client about sexual contacts during which time period? The past 21 days The past 30 days The past 3 months The past 6 months

3

A 12-year-old child with sickle cell anemia is admitted during a vaso-occlusive crisis. What is the priority of care for this child? Multiple choice question Relieving pain Exercising joints Increasing urine output Improving respirations

1

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What common complications of diabetes might the nurse expect to identify when assessing this client? . Leg ulcers Loss of visual acuity Thick, yellow toenails Increased growth of body hair Decreased sensation in the feet

1, 2, 3, and 5

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Tense fontanels High-pitched crying Apgar score of less than 5 A defect in the lumbosacral area Head circumference 2 cm greater than the chest circumference

1, 2, and 4

Which clinical manifestation occurs in a client with vasopressin deficiency? Impotence Hypotension Amenorrhea Decreased libido

2. Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.

The nurse is caring for a child with Reye syndrome. Which nursing interventions would be beneficial to the child? Initiate hyperventilation. Administer aspirin for fever. Assess the vital signs of the child. Monitor the child for seizure activity. Provide a quiet environment for the child.

1, 3,4,5

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Resting tremors Flattened affect Muscle flaccidity Tonic-clonic seizures Slow voluntary movements

1, 2, and 5. Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

Which assessment findings would cause a nurse to believe that a preschool-age client is not receiving enough vitamin C in the diet? Headaches Rashes Bleeding gums Muscle weakness Scaling of the skin

2 and 3.

The nurse is caring for a pregnant woman with class II cardiac disease. The client has anemia with a hemoglobin level of 8 g/dL (80 mmol/L). What is the nurse's primary concern for this client? Impending heart failure Development of heart block Appearance of atrial fibrillation Imminent ventricular fibrillation

1. Anemia reduces the capacity of the blood to carry oxygen and thus increases demands on the heart. Heart block is caused by a disturbance in the conduction of impulses, not the oxygen-carrying capacity of blood. Cardiac irregularity is not associated with anemia. Imminent ventricular fibrillation is a grave complication; adequate treatment should prevent this.

During thyroid surgery, a client's parathyroid glands have become damaged. Which condition does the nurse expect the client to develop? Goiter Tetany Globe lag Photophobia

2

Which conditions result in humoral immunity? Tuberculosis Atopic diseases Bacterial infection Anaphylactic shock Contact dermatitis

2, 3. and 4.

A 16-year-old client arrives at the clinic complaining of increased vaginal discharge, intermittent vaginal bleeding, excessive bleeding during menstruation, and pain in the lower abdomen. She relates an active sexual history with multiple partners. Which disease does the nurse suspect the client has? Herpes Syphilis Gonorrhea Toxoplasmosis

3. The client has signs and symptoms indicative of pelvic inflammatory disease, which is a complication of gonorrhea. Herpes is noted for its painful genital lesions; there are no data to indicate the presence of these lesions. The client does not have the signs and symptoms associated with syphilis or those associated with toxoplasmosis.

One evening an older client with a diagnosis of dementia chokes on a piece of food and becomes panicky and cyanotic. The nurse performs the abdominal thrust maneuver, and a bolus of food pops out of the client's mouth. After several deep respirations, the client's cyanosis passes. What is most appropriate for the nurse to do next? Inform the client that everything is fine. Stand the client up while checking the pulse. Touch the client's hand while providing verbal support. Teach the client how to prevent future similar problems.

3. The client will need reassurance and support after this frightening experience. Informing the client that everything is fine provides reassurance but no support. Standing the client up while checking the pulse is inappropriate; the priority is to allay anxiety; also, there is no need to stand the client up to take the pulse. The client has dementia and will have limited recall of recent teaching. Also, this is not the time for teaching.

A nurse is determining a client's heart rate on an ECG strip. Which action should the nurse take? Multiple choice question Count the P waves Count the T waves Count the PR interval Count the QRS complexes

4

Which sites would the nurse prefer while assessing for turgor in an older adult? Back of the neck Back of the hand Palm of the hand On the sternal area Back of the fore arm

4 and 5. Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.