Crisis 2 Exam 2 Book Questions BSN3

b

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. keeping the room dark and quiet to minimize environmental stimulation. d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.

c

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

b

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal.

d

A patient has had a cystectomy and ileal conduit diversion performed. Four days postoperatively, mucous shreds are seen in the drainage bag. The nurse should a. notify the physician. b. notify the charge nurse. c. irrigate the drainage tube. d. document it as a normal observation.

a

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys. b. a rapid decrease in urine output with an elevated BUN. c. an increasing creatinine clearance with a decrease in urine output. d. prostration, somnolence, and confusion with coma and imminent death.

a

A patient is admitted to the hospital with severe renal colic. The nurse's first priority in management of the patient is to a. administer opioids as prescribed. b. obtain supplies for straining all urine. c. encourage fluid intake of 3 to 4 L/day. d. keep the patient NPO in preparation for surgery.

c

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

a

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

b

A patient with a ureterolithotomy returns from surgery with a nephrostomy tube in place. Postoperative nursing care of the patient includes a. encouraging the patient to drink fruit juices and milk. b. encouraging fluids of at least 2 to 3 L/day after nausea has subsided. c. irrigating the nephrostomy tube with 10 mL of normal saline solution as needed. d. notifying the physician if nephrostomy tube drainage is more than 30 mL/hr.

b

A patient with acute hepatitis B is being discharged in 2 days. The discharge teaching plan should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.

a

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

d

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

b

A patient with kidney disease has oliguria and a creatinine clearance of 40 mL/min. These findings most directly reflect abnormal function of a. tubular secretion. b. glomerular filtration. c. capillary permeability. d. concentration of filtrate.

3

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Hemoglobin level of 14.0 g/dL (140 mmol/L) 2. Creatinine level of 0.6 mg/dL (53 mcmol/L) 3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L) 4. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L)

b

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

a,b,d

Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply) a. hypertension. b. vascular calcifications. c. a genetic predisposition. d. hyperinsulinemia causing dyslipidemia. e. increased high-density lipoprotein levels.

d

RIFLE defines three stages of AKI based on changes in a. blood pressure and urine osmolality. b. fractional excretion of urinary sodium. c. estimation of GFR with the MDRD equation. d. serum creatinine or urine output from baseline.

4

he mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side.

1,3,6

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort

3

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, painful scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

4

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

2

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

1

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

d

Which patient is most at risk for developing delirium? a. A 50-yr-old woman with cholecystitis b. A 19-yr-old man with a fractured femur c. A 42-yr-old woman having an elective hysterectomy d. A 78-yr-old man admitted to the medical unit with complications related to heart failure

b

Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory

a,b,c,d,e

Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

4,5

21. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. Intravenous opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

2

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats/minute 4. Respirations of 18 breaths/minute

a

A 50-yr-old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect that he has a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches.

c

A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.

4

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

4

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.

4,5,6

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

3

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

1,3,4

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1. Administer oxygen to the client. 2. Continue dialysis at a slower rate after checking the lines for air. 3. Notify the health care provider (HCP) and Rapid Response Team. 4. Stop dialysis, and turn the client on the left side with head lower than feet. 5. Bolus the client with 500 mL of normal saline to break up the air embolus.

4

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Swollen, and boggy prostate gland 3. Tender and edematous prostate gland 4. Tender, indurated prostate gland that is warm to the touch

1

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.

2

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1. Is disoriented to person, place, and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Demonstrates inability to add and subtract; does not know who is the president of the United States

4

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy

3

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage

4

A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting

2

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation

3

A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain

4

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

1

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1,3,4

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

4

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

1

A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP before performing the catheterization. 2. Use a small-sized catheter and an anesthetic gel as a lubricant. 3. Administer parenteral pain medication before inserting the catheter. 4. Clean the meatus with soap and water before opening the catheterization kit.

4

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red, bloody urine 2. Pain rated as 2 on a 0-10 pain scale 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

2

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only 3 large meals daily.

3

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding

4

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1. Diuretics 2. Antibiotics 3. Antilipemics 4. Decongestants

2

A client who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count

2

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed

3

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

4

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime

3

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."

1,2,4

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1

A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action? 1. Infusing slowly over 60 minutes 2. Infusing in a light-protective bag 3. Infusing only through a central line 4. Infusing rapidly as a direct IV push medication

1,2,4

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if any contain or retain potassium. 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 33% (0.33) 2. Platelet count of 400,000 mm3 (400 × 109/L) 3. White blood cell count of 6000 mm3 (6.0 × 109/L) 4. Blood urea nitrogen level of 15 mg/dL (5.25 mmol/L)

2

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5 °C (101.2 °F). Which nursing action is most appropriate? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

1

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Taking H2-receptor antagonist medication 4. Raising the head of the bed on 6-inch (15 cm) blocks

4

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

3

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Sodium level, 140 mEq/L (140 mmol/L) 2. Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3. White blood cell count, 3000 mm3 (3.0 × 109/L) 4. Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

4

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? 1. Sodium level of 140 mEq/L (140 mmol/L) 2. Platelet count of 400,000 mm3 (400 × 109/L) 3. Prothrombin time of 12 seconds (12 seconds) 4. Direct bilirubin level of 2 mg/dL (34 mcmol/L)

c

A diagnostic study that indicates renal blood flow, glomerular filtration, tubular function, and excretion is a(n) a. IVP. b. VCUG. c. renal scan. d. loopogram.

4

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

a

A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection. b. Reassure the patient that this is common after transplantation. c. Provide warm cover for the patient and give 1 g acetaminophen orally. d. Notify the nephrologist that the patient has developed symptoms of acute rejection.

3

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

a

A major advantage of peritoneal dialysis is a. the diet is less restricted and dialysis can be performed at home. b. the dialysate is biocompatible and causes no long-term consequences. c. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss. d. no medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins.

4

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

4

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. Side or prone 2. Back or prone 3. Stomach with the face turned 4. Back rather than on the stomach

b

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

c

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum. b. resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum. c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum. d. radical removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.

a

A priority goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.

d

A renal stone in the pelvis of the kidney will alter the function of the kidney by interfering with the a. structural support of the kidney. b. regulation of the concentration of urine. c. entry and exit of blood vessels at the kidney. d. collection and drainage of urine from the kidney.

4

A week after kidney transplantation, a client develops a temperature of 101 °F (38.3 °C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. Antibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy

a

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection. d. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails.

2

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

3

An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations

2

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

c

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours

4

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

a,d,e

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

d

Dementia is defined as a a. syndrome that results only in memory loss. b. disease associated with abrupt changes in behavior. c. disease that is always due to reduced blood flow to the brain. d. syndrome characterized by cognitive dysfunction and loss of memory.

c

Dementia with Lewy bodies (DLB) is characterized by a. remissions and exacerbations over many years. b. memory impairment, muscle jerks, and blindness. c. parkinsonian symptoms, including muscle rigidity. d. increased intracranial pressure secondary to decreased CSF drainage.

c

Diminished ability to concentrate urine, associated with aging of the urinary system, is attributed to a. a decrease in bladder sensory receptors. b. a decrease in the number of functioning nephrons. c. decreased function of the loop of Henle and tubules. d. thickening of the basement membrane of Bowman's capsule.

a

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a

During physical assessment of the urinary system, the nurse a. cannot palpate the left kidney b. palpates an empty bladder as a small nodule. c. finds a dull percussion sound when 100 mL of urine is present in the bladder. d. palpates above the symphysis pubis to determine the level of urine in the bladder.

b,d

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes. c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity.

c

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

a

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information necessary for the patient to make decisions regarding liver transplantation.

a

In planning nursing interventions to increase bladder control in the patient with urinary incontinence, the nurse includes a. teaching the patient to use Kegel exercises. b. clamping and releasing a catheter to increase bladder tone. c. teaching the patient biofeedback mechanisms to suppress the urge to void. d. counseling the patient concerning choice of incontinence containment device

d

In teaching a patient with pyelonephritis about the disorder, the nurse informs the patient that the organisms that cause pyelonephritis most commonly reach the kidneys through a. the bloodstream. b. the lymphatic system. c. a descending infection. d. an ascending infection.

d

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

2,3,4

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

4

Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

a,d

Normal findings expected by the nurse on physical assessment of the urinary system include (select all that apply) a. nonpalpable left kidney. b. auscultation of renal artery bruit. c. CVA tenderness elicited by a kidney punch. d. no CVA tenderness elicited by a kidney punch. e. palpable bladder to the level of the pubic symphysis.

a,b,d,e

Nurses must teach patients at risk for developing chronic kidney disease. Individuals considered to be at increased risk include (select all that apply) a. older African Americans. b. patients more than 60 years old. c. those with a history of pancreatitis. d. those with a history of hypertension. e. those with a history of type 2 diabetes.

c,e

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

a,e

Nursing management of the patient with acute pancreatitis includes (select all that apply) a. checking for signs of hypocalcemia. b. providing a diet low in carbohydrates. c. giving insulin based on a sliding scale. d. observing stools for signs of steatorrhea. e. monitoring for infection, particularly respiratory tract infection.

a,b,c

Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements would be considered true related to nutritional therapy (select all that apply)? a. Fluid is not usually restricted for patients receiving peritoneal dialysis. b. Sodium and potassium may be restricted in someone with advanced CKD. c. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving hemodialysis. d. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis. e. Decreased fluid intake and a diet with phosphate-rich foods are hallmarks of a diet for a patient receiving hemodialysis.

d

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-yr-old Native American. b. 35-yr-old Asian American woman who smokes. c. 32-yr-old white woman taking oral contraceptives. d. 65-yr-old African American man with hypertension.

d

On reading the urinalysis results of a dehydrated patient, the nurse would expect to find a. a pH of 8.4. b. RBCs of 4/hpf. c. color: yellow, cloudy. d. specific gravity of 1.035.

a

One of the nurse's most important roles in relation to acute poststreptococcal glomerulonephritis is to a. promote early diagnosis and treatment of sore throats and skin lesions. b. encourage patients to obtain antibiotic therapy for upper respiratory tract infections. c. teach patients with APSGN that long-term prophylactic antibiotic therapy is necessary to prevent recurrence. d. monitor patients for respiratory symptoms that indicate the disease is affecting the alveolar basement membrane.

4

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

2

Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation? 1. Urine is clear amber. 2. Urination is not painful. 3. Urge incontinence is not present. 4. A reddish-orange discoloration of the urine is present.

4

Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when teaching the client about this medication? 1. Eat at frequent intervals to avoid hypoglycemia. 2. Take the medication with a full glass of grapefruit juice. 3. Change positions carefully due to risk of orthostatic hypotension. 4. Take the oral medication every 12 hours at the same times every day.

b

Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.

1

The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Photosensitivity

4

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

1

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

d

The clinical diagnosis of dementia is based on a. CT or MRS. b. brain biopsy. c. electroencephalogram. d. patient history and cognitive assessment.

b

The early stage of AD is characterized by a. no noticeable change in behavior. b. memory problems and mild confusion. c. increased time spent sleeping or in bed. d. incontinence, agitation, and wandering behavior.

d

The edema that occurs in nephrotic syndrome is due to a. increased hydrostatic pressure caused by sodium retention. b. decreased aldosterone secretion from adrenal insufficiency. c. increased fluid retention caused by decreased glomerular filtration. d. decreased colloidal osmotic pressure caused by loss of serum albumin.

2

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting himself or herself with the hands and arms.

c

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. O2 content of the blood. c. degree of collateral circulation. d. level of CO2 in the blood.

2

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1. "I have had unprotected sex with multiple partners." 2. "I ate shellfish about 2 weeks ago at a local restaurant." 3. "I was an intravenous drug abuser in the past and shared needles." 4. "I had a blood transfusion 30 years ago after major abdominal surgery."

3

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? 1. Pregnancy must be avoided while taking phenytoin. 2. The client may stop the medication if it is causing severe gastrointestinal effects. 3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. 4. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

b

The immunologic mechanisms involved in acute poststreptococcal glomerulonephritis include a. tubular blocking by precipitates of bacteria and antibody reactions. b. deposition of immune complexes and complement along the GBM. c. thickening of the GBM from autoimmune microangiopathic changes. d. destruction of glomeruli by proteolytic enzymes contained in the GBM.

a,c

Which descriptions characterize acute kidney injury (select all that apply)? a. Primary cause of death is infection. b. It almost always affects older people. c. Disease course is potentially reversible. d. Most common cause is diabetic nephropathy. e. Cardiovascular disease is most common cause of death.

3

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

4

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

1,2,4

The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply. 1. "I will take the cimetidine with my meals." 2. "I'll know the medication is working if my diarrhea stops." 3. "My episodes of heartburn will decrease if the medication is effective." 4. "Taking the cimetidine with an antacid will increase its effectiveness." 5. "I will notify my health care provider if I become depressed or anxious." 6. "Some of my blood levels will need to be monitored closely since I also take warfarin for atrial fibrillation."

1,3,4

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy

c

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

d

The nurse finds an 87-yr-old woman with Alzheimer's disease is continually rubbing, flexing, and kicking her legs throughout the day. The night shift reports this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to a. ask the physician for a daytime sedative for the patient. b. request soft restraints to prevent her from falling out of her bed. c. ask the physician for a nighttime sleep medication for the patient. d. assess the patient more closely, suspecting a disorder such as restless legs syndrome.

2

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. I will wash the skin daily under the lamb's wool liner of the vest."

3

The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction? 1. "I will continue taking vitamin supplements." 2. "This medication will help to lower my cholesterol." 3. "This medication should only be taken with water." 4. "A high-fiber diet is important while taking this medication."

4

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on my unaffected side." 3. "I should rinse my mouth if toothbrushing is painful." 4. "I'll try to eat my food either very warm or very cold."

4

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

3

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form." 2. "I hope the throat spray keeps me from gagging." 3. "I'm glad I don't have to lie still for this procedure." 4. "I'm glad some intravenous medication will be given to relax me."

b

The nurse identifies a risk factor for kidney and bladder cancer in a patient who relates a history of a. aspirin use. b. tobacco use. c. chronic alcohol abuse. d. use of artificial sweeteners.

d

The nurse identifies a risk for urinary calculi in a patient who relates a past health history that includes a. hyperaldosteronism. b. serotonin deficiency. c. adrenal insufficiency. d. hyperparathyroidism.

4

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

c

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

1,2,4

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

3

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription? 1. Obtain daily weight. 2. Provide clear liquid intake. 3. Nasotracheal suction as needed. 4. Maintain a patent intravenous line.

3

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

4

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed? 1. Pentostatin 2. Auranofin 3. Fludarabine 4. Acetylcysteine

1,3,4

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

2

The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication? 1. Monitor radial pulse. 2. Monitor bowel activity. 3. Monitor apical heart rate. 4. Monitor peripheral pulses.

2

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a room with another child with RSV. 3. Leave the infant in the present room because RSV is not contagious. 4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

4

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine

1,3,5

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

3

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

3

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

1,2,5,6

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

4

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

2

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

1,2,5

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

1

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the health care provider (HCP). 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

1

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

4

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, boardlike abdomen

4

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the health care provider (HCP).

4

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

1,2,3,5

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1,6

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

2

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semi-formed stool noted in the ostomy pouch

3

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet? 1. Red meats 2. Orange juice 3. Grapefruit juice 4. Green, leafy vegetables

1,3,5

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. 1. Nuts 2. Corn 3. Liver 4. Apples 5. Lentils 6. Bananas

3

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.

2

The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list? 1. Advise that sunscreen is not needed. 2. Drink 8 to 10 glasses of water per day. 3. If the urine turns dark brown, call the health care provider (HCP) immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response.

1

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. "I should increase the fiber in my diet." 2. "I will need to avoid caffeinated beverages." 3. "I'm going to learn some stress reduction techniques." 4. "I can have exacerbations and remissions with Crohn's disease."

d

The nurse is reinforcing teaching with a patient newly diagnosed with amyotrophic lateral sclerosis (ALS). Which statement would be appropriate to include in the teaching? a. "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." b. "Even though the symptoms you are experiencing are severe, most people recover with treatment." c. "You need to consider advance directives now, because you will lose cognitive function as the disease progresses." d. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."

1

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Increased number of white blood cells in the urine

3

The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. Potassium level of 3.8 mEq/L (3.8 mmol/L) 2. Platelet count of 300,000 mm3 (300 × 109/L) 3. Fasting blood glucose of 200 mg/dL (11.1 mmol/L) 4. White blood cell count of 6000 mm3 (5 to 10 × 109/L)

3

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

3

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.

1

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

1,2,4,5

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

c

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting

1

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1. "I need to limit my intake of dietary fiber." 2. "I need to drink plenty, at least 8 to 10 cups daily." 3. "I need to eat regular meals and chew my food well." 4. "I will take the prescribed medications because they will regulate my bowel patterns."

1

The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response? 1. "Continue taking the medication; the brown urine occurs and is not harmful." 2. "Take magnesium hydroxide with your medication to lighten the urine color." 3. "Discontinue taking the medication and make an appointment for a urine culture." 4. "Decrease your medication to half the dose, because your urine is too concentrated."

d

The nurse recommends genetic counseling for the children of a patient with a. nephrotic syndrome. b. chronic pyelonephritis. c. malignant nephrosclerosis. d. adult-onset polycystic kidney disease.

b

The nurse teaches the female patient who has frequent UTIs that she should a. take tub baths with bubble bath. b. urinate before and after sexual intercourse. c. take prophylactic sulfonamides for the rest of her life. d. restrict fluid intake to prevent the need for frequent voiding.

d

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

3

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A chronic disability characterized by impaired muscle movement and posture 4. A congenital condition that results in moderate to severe intellectual disabilities

b

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

c,d,e

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm. b. irrigate the graft daily with low-dose heparin. c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. frequently monitor the pulses and neurovascular status distal to the graft.

4

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat

c

Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.

b

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

2

he nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1. "Alcohol is not contraindicated while taking this medication." 2. "Good oral hygiene is needed, including brushing and flossing." 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication should be taken before a serum medication level is drawn."

3

he nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Document the findings. 4. Notify the health care provider.

3

he nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration