NDEE Evolve

During a home visit to a client, the nurse identifies the tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the colors of shirts are getting tight. Which additional assessment would the nurse report immediately to the healthcare provider? a. increased appetite b. recent weight loss c. feelings of warmth d. fluttering in the chest

d. fluttering in the chest (palpitations may indicate cardiovascular changes requiring prompt intervention)

Which complication would the nurse be concerned about if there is removal of the parathyroid glands during a thyroidectomy? a. tetany b. myxedema c. hypovolemic shock d. adrenocortical stimulation

a. tetany

The nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the mid-abdomen, which type of sound would the nurse expect to hear? a. tympany b. borborygmi c. abdominal bruit d. pleural friction rub

b. borborygmi these sounds occur behind an intestinal obstruction

A client is admitted to the hospital with a diagnosis of intestinal obstruction and has an intestinal tube inserted. As prescribed, the nurse instills 30 mL of normal saline into the tube to maintain patency. Which action would the nurse take next? a. add 30 mL to the gastric output on the intake and output record b. record 30 mL as intake in the intake and output record c. recognize that the amount instilled equals insensible losses d. identify that the amount is insignificant and does not need to be documented

b. record 30 mL as intake in the intake and output record

Which complication would the nurse monitor in a client with hyperparathyroidism? a. tetany b. seizures c. bone pain d. Graves disease

c. bone pain (hyperparathyroidism causes calcium release from the bones, leaving them porous, weak, and painful)

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. Which client response would the nurse critically assess? a. edema b. belching c. fluid deficit d. excessive salivation

c. fluid deficit

A client experiences occasional right upper quadrant pain attributed to cholecystitis. To prevent or minimize dyspepsia, the nurse would instruct the client to avoid which food items? a. nuts and popcorn b. meatloaf and baked potato c. chocolate and boiled shrimp d. fried chicken and buttered corn

d. fried chicken and buttered corn

Which factor may contribute to a client developing urinary calculi? a. increased fluid intake b. urine specific gravity of 1.017 c. jogging 3 miles (4.8 km) a day d. history of hyperparathyroidism

d. history of hyperparathyroidism

The nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included in the diet. Which food choices indicate that the teaching by the nurse was effective? (SATA) a. orange juice b. creamed soup c. jelly sandwich d. lean roast beef e. scrambled eggs

c. jelly sandwich d. lean roast beef e. scrambled eggs

Which situation in a client with hyperthyroidism may precipitate thyroid crisis (thyroid storm)? a. increased iodine in the blood b. removal of the parathyroid glands c. high levels of the hormone triiodothyronine d. rebound increase in metabolism after anesthesia

c. high levels of the hormone triiodothyronine (T3 hormone intensifies all the S/S of hyperthyroidism such as increased temperature, pulse, and respirations, restlessness, vomiting, and often death)

The nurse is caring for a client who has renal calculi secondary to hyperparathyroidism. Which type of diet would the nurse teach the client? a. low purine b. low calcium c. high phosphorus d. high alkaline ash

b. low calcium

A client with an acute attack of cholecystitis has a cholecystectomy with a choledochotomy. The client returns from surgery with a T-tube connected to a drainage bag. What would the nurse conclude is the purpose of the T-tube? a. decreases edema b. permits drainage of bile c. insert antibiotic medication d. provide irrigation of the gallbladder

b. permits drainage of bile

A primary health care provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings would the nurse expect when performing a health history and physical assessment? (SATA) a. diarrhea with black feces b. intolerance to foods high in fat c. vomiting of coffee-ground emesis d. Gnawing pain when stomach is empty e. pain that radiates to the right shoulder

b. intolerance to foods high in fat e. pain that radiates to the right shoulder

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer? a. the pain intensifies after vomiting stomach contents b. the pain occurs 1 to 2 hours after having a meal c. the pain increases when ingesting an excess of fatty foods d. the pain begins in the epigastrium and radiates to the abdomen

b. the pain occurs 1 to 2 hours after having a meal

A client with cholecystitis is placed on a low fat, high protein diet. What nutrient should the nurse teach the client is included with this diet? a. Skim milk b. Boiled beef c. Poached eggs d. Steamed broccoli

a. Skim milk

A self-help group of clients with IBS have invited the nurse to present a program on nutrition. Which substance would the nurse teach the clients to minimize in the diet to decrease gastrointestinal irritability? a. cola drinks b. gelatin c. fiber d. rice

a. cola drinks

Which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy? (SATA) a. fatigue b. dry skin c. insomnia d. excitability e. weight loss f. intolerance to heat

a. fatigue b. dry skin

The nurse is obtaining a health history from a client with a diagnosis of peptic ulcer disease. The nurse identifies a possible contributory risk factor when the client makes which statement? a. "My blood type is A positive." b. "I smoke one pack of cigarettes a day." c. "I have been overweight most of my life." d. "My blood pressure has been high lately."

b. "I smoke one pack of cigarettes a day."

A client is admitted to the hospital with a diagnosis of peptic ulcer. Which common complication would the nurse assess for in this client? a. perforation b. hemorrhage c. pyloric obstruction d. esophageal varices

b. hemorrhage

Which serum blood level would the nurse expect to be DECREASED in a client with a diagnosis of hyperparathyroidism? a. calcium b. chloride c. phosphorus d. parathyroid hormone

c. phosphorus

The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? a. gastritis b. hiatal hernia c. diverticulosis d. bowel obstruction

d. bowel obstruction

The nurse identifies which clinical manifestations as being characteristic of hyperthyroidism? (SATA) a. diaphoresis b. weight loss c. constipation d. protruding eyes e. cold intolerance

a. diaphoresis b. weight loss d. protruding eyes

The nurse is assessing female clients and identifies that which client has the greatest risk of developing gallbladder disease? a. older than age 40 & obese b. older than age 40 with a low serum cholesterol level c. less than 40 years of age with a history of high fat intake d. less than 40 years of age with a family history of gallstones

a. older than 40 & obese Remember (4F's- female fat, forty, fertile(

An infant with congenital hypothyroidism receives levothyroxine for 3 months. Which finding would indicate to the nurse that the medication is effective? a. the infant is alert and interactive b. the skin is cool to the touch c. the baby's fine tremor has ceased d. the baby's thyroid stimulating hormone level has increased

a. the infant is alert and interactive

An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet would the nurse encourage the client to follow? a. low-fat b. high-fiber c. high-protein d. low-carbohydrate

b. high-fiber Helps prevent constipation

Which equipment would the nurse include when setting up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy? a. crash cart with bed board b. tracheostomy set and oxygen c. ampule of sodium bicarbonate d. airway and nonrebreather mask

b. tracheostomy set and oxygen

The nurse reviews the room assignments for clients who are scheduled for admission. One client is being hospitalized to receive intravenous steroids for management of Crohn disease. The nurse would question the assignment if the client is scheduled to have a roommate who has which illness? a. pancreatitis b. thrombophlebitis c. bacterial meningitis d. acute cholecystitis

c. bacterial meningitis

The nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result would confirm the diagnosis? a. digital rectal examination b. serum phosphatase level c. biopsy of prostatic tissue d. massage of prostatic fluid

c. biopsy of prostatic tissue

A client is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis? a. urinary retention b. gastric hyperacidity c. rebound tenderness d. increased lower bowel motility

c. rebound tenderness

Assessment findings of a patient who is admitted to the emergency department include cramping pain in the left lower quadrant, weakness, bloating malaise, and a low-grade fever. The nurse suspects which condition? a. pancreatitis b. appendicitis c. cholecystitis d. diverticulitis

d. diverticulitis

After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. Which nursing assessment helps confirm the diagnosis of intussusception? a. auscultating for bowel sounds b. listening for high-pitched crying c. measuring fluid intake and output d. observing characteristics of stools

d. observing characteristics of stools

Which explanation would the nurse provide when responding to a client's inquiry about intussusception of the bowel? a. "It is kinking of the bowel onto itself." b. "It is a band of connective tissue compressing the bowel." c. "It is telescoping of a proximal loop of bowel into a distal loop." d. "It is a protrusion of an organ or part of an organ through the wall that contains it."

c. "It is telescoping of a proximal loop of bowel into a distal loop."