NUR 131 HESI EAQ Practice Exam 3
γ-Benzene hexachloride is used to treat lesions caused by...?
lice on various parts of the body
Which clinical finding would indicate possible meningitis in an infant with an infected ventriculoperitoneal shunt? Select all that apply. One, some, or all responses may be correct. (1) Fever (2) Lethargy (3) Stiff neck (4) Poor feeding (5) Depressed fontanels
(1) Fever (2) Lethargy (3) Stiff neck (4) Poor feeding - - low grade fever progressing to high grade fever occurs in meningitis - - infectious process that causes meningitis may cause rigidity and hyperextension of the neck (opisthotonos) - - CNS irritation results in irritability, lethargy, and anorexia
what blood tests is used to confirm prostate cancer?
(1) PSA - prostate specific antigen - - normal range is 0-4 ng/mL (2) PAP prostatic acid phosphatase
common manifestation of scabies
(1) Pruritic, threadlike lesions in skin folds
Which condition would a nurse suspect when a client with a skin infection reports an itching sensation associated with pain at the site of infection and shows erythematous blisters and interdigital scaling and maceration? (1) Tinea pedis (2) Tinea cruris (3) Tinea corporis (4) Tinea unguium
(1) Tinea pedis RATIONALE: (1) tinea pedis is usually manifested as interdigital scaling and maceration and a scaly plantar surface sometimes with erythema and blistering
what is the major route of sodium excretion?
(1) the kidneys under the control of aldosterone
Which bacterial condition is suspected when a client with vesiculopustular lesions with honey-colored crusts on the face visits a primary health care provider? (1) Cellulitis (2) Impetigo (3) Carbuncle (4) Erysipelas
(2) Impetigo - - is associated with vesiculopustular lesions that have honey-colored crusts and usually manifests on the face
When monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? Select all that apply. One, some, or all responses may be correct. (1) Thirst (2) Seizures (3) Erythema (4) Confusion (5) Constipation
(2) Seizures (4) Confusion - - cellular swelling and cerebral edema are associated with hyponatremia - as ECF sodium level decreases the cellular fluid become more concentrated and pulls water into the cerebral cells leading to confusion and seizures
Which pathophysiological rationale explains why a client who is 4 days postabdominal surgery has not passed flatus and has hypoactive bowel sounds and why a paralytic ileus is suspected of developing? (1) Decreased blood supply (2) Impaired neural functioning (3) Perforation of the bowel wall (4) Obstruction of the bowel lumen
(2) Impaired neural functioning RATIONALE: (1) paralytic ileus occurs when neurological impulses diminish result from anesthesia, infection, or surgery
A child who has recently been diagnosed with a brain tumor vomits during breakfast. Which nursing intervention is priority? Select all that apply. One, some, or all responses may be correct. (1) Refeeding breakfast (2) Notifying the practitioner (3) Requesting a reevaluation (4) Administering the prescribed antiemetic (5) Increasing the intravenous infusion rate
(2) Notifying the practitioner (3) Requesting a reevaluation RATIONALE: (1) when showing signs of elevated ICPs the provider should be notified and conduct a repeat assessment (2) refeeding breakfast is unsafe (3) if cause of vomiting is increased ICPs then antiemetics will not be effective (4) additional fluids may further increase the ICPs
Which explanation would the nurse provide when responding to a client's inquiry about intussusception of the bowel? (1) "It is kinking of the bowel onto itself." (2) "It is a band of connective tissue compressing the bowel." (3) "It is telescoping of a proximal loop of bowel into a distal loop." (4) "It is a protrusion of an organ or part of an organ through the wall that contains it."
(3) "It is telescoping of a proximal loop of bowel into a distal loop."
Acute appendicitis develops in an older client with a history of chronic constipation. Before arrival at the hospital, the client attempted self-care at home. Which self-care measure could potentially lead to rupture of the appendix? (1) Avoiding food and liquids because of nausea (2) Applying an ice pack to the abdomen (3) Self-administering a small-volume enema (4) Taking acetaminophen for pain
(3) Self-administering a small-volume enema - - could increase pressure in the intestines causing the appendix to rupture
Which disorder would the nurse suspect in a client reporting dysuria, hesitancy, urinary urgency, and urinary leakage whose serum prostate- specific antigen (PSA) level is 5 ng/mL with an elevated prostatic acid phosphatase (PAP) level? (1) Orchitis (2) Hydrocele (3) Prostatitis (4) Prostate cancer
(4) Prostate cancer
Which medication would the nurse expect to be prescribed for a client who has burrows with erythematous papules and vesicles with interdigital web crusting?
(1) 5% Permethrin lotion ➡️ - - above s/s are indications of scabies and this medicine is used to treat scabies
A client is scheduled for surgery to repair an irreducible (incarcerated) hernia. Which nursing intervention is the priority? (1) Assessing the client's bowel movements (2) Maintaining the client in the proper position (3) Checking the client's vital signs periodically (4) Monitoring the client's serum enzyme levels
(1) Assessing the client's bowel movements - - possible complication of a hernia is intestinal obstruction
Doxycycline is used to treat...?
lyme disease
what is cellulitis?
a bacterial infection in which hot, tender, erythematous, and edematous areas with diffuse borders are present
Which early clinical manifestations would the nurse expect in a preschool-aged child with an aspirin overdose? Select all that apply. One, some, or all responses may be correct. (1) Emesis (2) Nausea (3) Tinnitus (4) Ecchymosis (5) Hypoventilation
(1) Emesis (2) Nausea (3) Tinnitus RATIONALE: (1) emesis, tinnitus, and nausea are all early signs of acute aspirin poisoning (2) hyperventilation not hypoventilation is an early sign of aspirin overdose
Which situations are common negligent acts of nurses found in the hospital setting? Select all that apply. One, some, or all responses may be correct. (1) Failure to notify the health care provider of problems (2) Failure to follow the six rights of medication administration (3) Failure to ensure the safety of a client with disequilibrium problems (4) Failure to notify a family member about the client's current status (5) Failure to administer medication during an emergency without consulting with the nursing manager
(1) Failure to notify the health care provider of problems (2) Failure to follow the six rights of medication administration (3) Failure to ensure the safety of a client with disequilibrium problems
what is urticaria?
(1) allergic skin condition (2) causes a local increased in the permeability of capillaries which cause erythema and edema in the upper dermis
Which topical medication is typically used to treat a client with acne vulgaris? Select all that apply. One, some, or all responses may be correct. (1) Mupirocin (2) Gentamicin (3) Clindamycin (4) Erythromycin (5) Metronidazole
(3) Clindamycin (4) Erythromycin RATIONALE:
what is atopic dermatitis
(1) genetically influenced, chronic, relapsing disease (2) associated with immunological irregularity involving inflammatory mediators that are associated with allergic rhinitis and asthma
medicine for gram (-) organisms
(1) gentamicin
what is the client with liver disease at risk for?
(1) gynecomastia
initial s/s of bowel obstruction
(1) increased peristalsis and bowel sounds
medicine for rosacea and bacterial vaginosis
(1) metronidazole
medicines for impetigo
(1) mupirocin
A client with cholelithiasis has a laser laparoscopic cholecystectomy. Which nursing intervention is appropriate for the postoperative plan of care? (1) Maintain the client's nothing-by-mouth status for the first 24 hours. (2) Monitor the client's abdominal incision for bleeding. (3) Offer clear, carbonated beverages to the client. (4) Ambulate the client when the client is alert and oriented.
(4) Ambulate the client when the client is alert and oriented.
A 4-year-old child is found to have Hirschsprung disease (aganglionic megacolon). Which diet recommendations would the nurse provide the parents? (1) High-fat (2) High-fiber (3) Low-calorie (4) Low-residue
(4) Low-residue - - important to prevent the development of bulk which might further irritate the colon - - a high fiber diet is contraindicated because it may cause an obstruction
what does a hard, hot, painful reddened area in the breast suggest?
an abscess
Chlorocyclohexane is used to control.....?
bedbugs
what is a late sign of aspirin overdose
ecchymosis
hypokalemia or hyperkalemia: anorexia
hypokalemia
necrosis results when..?
there is an interference in blood supply
Which instruction would the nurse include in discharge teaching for a client who has had an anteriorposterior colporrhaphy? (1) Eating a high-fiber diet (2) Limiting daily activities (3) Reporting signs of urine retention (4) Being alert to signs of a rectovaginal fistula
(1) Eating a high-fiber diet - - this surgery causes pain associated with bearing down so increasing fluids, fiber, and activity can help to prevent constipation - - this surgery is expected to reduce incontinence and urine retention is not expected - - surgery involves only the vaginal wall - the rectum should not be involved
Which nursing intervention would the nurse provide a 3-week-old infant immediately after surgery for esophageal atresia? (1) Restarting oral feedings slowly (2) Reporting vomiting to the health care provider (3) Checking the patency of the nasogastric tube (4) Monitoring the child for signs of infection at the incision site
(3) Checking the patency of the nasogastric tube RATIONALE: (1) appropriate nursing action immediately post-op is to check the patency of the tube
Which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? Select all that apply. One, some, or all responses may be correct. (1) Anorexia (2) Constipation (3) Muscle weakness (4) Irregular heart rhythm (5) Hyperactive bowel tones
(3) Muscle weakness (4) Irregular heart rhythm (5) Hyperactive bowel tones RATIONALE: (1) increase in potassium interferes with muscle contractions - results in muscle weakness and areflexia (2) most serious complication of hyerkalemia are fatal cardiac rhythms (complete heart block, asystole, and ventricular fibrillation)
Which is the priority of care for a child who was recently diagnosed with celiac disease? (1) Preventing celiac crisis and resulting problems (2) Minimizing complications of respiratory involvement (3) Teaching the parents to establish a diet that promotes optimal growth (4) Helping the parents and child adjust to the long-term dietary restrictions
(4) Helping the parents and child adjust to the long-term dietary restrictions RATIONALE: (1) adherence to dietary restrictions can prevent a celiac crisis (2) celiac crisis usually result from nonadherence to the diet so adherence would be the primary objective (3) teaching parents to establish a growth-encouraging diet is incorrect because regardless of adherence to the diet the disease may interfere with the expected growth rate
Which position would the nurse use for an infant who will have a lumbar puncture? (1) Sitting with the buttocks at the table's edge and the head flexed (2) Prone with the head extended over the table's edge and the extremities swaddled (3) Lateral recumbent with the back at the table's edge and the head and legs extended (4) Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin
(4) Side-lying with the back at the table's edge and the head flexed with the knees brought to the chin - - this position with the head and hips flexed separates the vertebrae making needle insertion easier and also permits better restraint by the nurse - - sitting position is sometimes used for adults but does not work for children because of difficulty keeping them still
what is carbuncle?
a bacterial infection with many pustules in an erythematous area
While assessing a client's hair, the nurse notices the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which client statement indicates an understanding of the teaching? Select all that apply. One, some, or all responses may be correct. (1) "I will clean my comb in ammonia water." (2) "I should use lindane-containing shampoo." (3) "I should shampoo my hair in a tub or shower." (4) "I should use a dilute vinegar solution to loosen the nits." (5) "I should use a shampoo treatment once every 24 hours."
(1) "I will clean my comb in ammonia water." (4) "I should use a dilute vinegar solution to loosen the nits." (5) "I should use a shampoo treatment once every 24 hours."
Which assessment data would cause the nurse to suspect that a toddler- age child is experiencing physical neglect? (1) Abdominal distention (2) Bloody underclothing (3) Recurrent urinary tract infections (4) Bruises in various stages of healing
(1) Abdominal distention RATIONALE: (1) abdominal distention is a physical manifestation associated with malnutrition which is typically seen in physical neglect (2) bruises in various stages of healing are associated with physical abuse not physical neglect
The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? (1) Hypokalemia (2) Hyperkalemia (3) Hyponatremia (4) Hypernatremia
(1) Hypokalemia
Which factor increases the risk for testicular cancer in adolescent clients? Select all that apply. One, some, or all responses may be correct. (1) Infertility (2) Hemophilia (3) Liver disease (4) Cryptorchidism (5) Klinefelter syndrome
(1) Infertility (4) Cryptorchidism (5) Klinefelter syndrome
While in the playroom, a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. Which action would the nurse take after moving the child to the floor? (1) Moving objects away from the child (2) Taking the other children to their rooms (3) Inserting a plastic airway into the child's mouth (4) Positioning a large pillow under the child's head
(1) Moving objects away from the child - - safety is the priority during a seizure
what is potassium and phosphorous not related to the development of?
(1) tetany
Which early sign of impending hydrocephalus would the nurse monitor for in an infant who has had surgery for repair of a myelomeningocele? (1) Frequent crying (2) Bulging fontanels (3) Change in vital signs (4) Difficulty with feeding
(2) Bulging fontanels RATIONALE: (1) after closure spinal fluid can buildup and reach the brain causing an increase in ICP and thus bulging fontanels
When assessing a toddler with autism spectrum disorder (ASD), which characteristic findings or behaviors would the nurse expect? Select all that apply. One, some, or all responses may be correct. (1) The desire to hug the nurse (2) Flat, blank facial expression (3) Laughing when pulse is taken (4) Inability to maintain eye contact (5) Enjoys climbing on stairs and furniture
(2) Flat, blank facial expression (3) Laughing when pulse is taken (4) Inability to maintain eye contact RATIONALE: (1) characteristics expected from a toddler with ASD would be a flat effect, inappropriate laughing while measuring pulse, lack of eye contact, and humming/grunting (2) tend to over-respond to environmental stimuli (3) will rarely hug anyone and would not enjoy climbing on furniture
Which clinical manifestation is an early indicator of intestinal strangulation from bilateral inguinal hernias? (1) Increased flatus (2) Projectile vomiting (3) Sharp abdominal pain (4) Decreased bowel sounds
(3) Sharp abdominal pain - - pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia - - vomiting would be persistent not projectile
While in a restaurant, a 10-month-old infant gags and then turns cyanotic. With permission from the family, which action would the nurse take while holding the child with the head downward? (1) Gives the infant 5 back blows (2) Sweeps the infant's mouth with a finger (3) Performs 5 abdominal thrusts on the infant (4) Initiates the head tilt-chin lift maneuver on the infant
(1) Gives the infant 5 back blows RATIONALE: (1) if younger than 1 year and experiencing an airway obstruction they should be held with their head down and given 5 back blows (2) if obstruction is not removed after blows then give them 5 chest thrusts (3) above 2 actions are alternated into the obstruction is dislodged or infant loses consciousness (4) abdominal thrusts (heimlich manuever) is the first action for children over 1 year of age and adults (5) if the infant becomes unconscious then a modified head tilt-chin lift is performed before the initiation of resuscitation
Which condition in the gynecological history of the client scheduled for hysterectomy causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy? (1) Prolapsed uterus (2) Large uterine fibroids (3) Mild dysplasia of the cervical os (4) Urinary incontinence when coughing
(2) Large uterine fibroids RATIONALE: (1) removing a uterus with large fibroids vaginally could cause trauma resulting in hemorrhage (2) vaginal hysterectomy is indicated for a prolapsed uterus (uterus is collapsed inside the vagina) (3) hysterectomy is not the treatment of choice for mild cervical dysplasia (4) when a hysterectomy is performed the vaginal route is preferred
Which assessment finding in a client with acute lymphoblastic leukemia receiving chemotherapy would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct. (1) Fever (2) Diarrhea (3) Melena (4) Hematuria (5) Ecchymosis
(3) Melena (4) Hematuria (5) Ecchymosis - - thrombocytopenia condition with abnormally low levels of thrombocytes (platelets) - - reduction in platelet activity impairs blood clotting so assessment findings associated with abnormal bleeding would be an indicator
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? (1) Urticaria (2) A medication reaction (3) Atopic dermatitis (4) Contact dermatitis
(4) Contact dermatitis - - Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens
Which complication would the nurse suspect in the client who returns to the unit after an abdominal hysterectomy with an indwelling urine catheter present and sanguineous urine in the collection bag? (1) An incisional nick in the bladder (2) A urinary infection from the catheter (3) Disseminated intravascular coagulopathy (4) Uterine relaxation with increased bleeding
(1) An incisional nick in the bladder - - During an abdominal hysterectomy the urinary bladder may be nicked accidentally. - - The client is not likely to have an infection with bleeding so soon after surgery.
The nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the client's history most likely played a role in the development of hemorrhoids? Select all that apply.One, some, or all responses may be correct. (1) Constipation (2) Hypertension (3) Eating spicy foods (4) Bowel incontinence (5) Numerous pregnancies
(1) Constipation (5) Numerous pregnancies RATIONALE: (1) straining from constipation increases intra-abdominal pressure/portal venous pressure which increases the risk for hemorrhoids (2) enlarging uterus from pregnancies puts pressure on inferior cava that can lead to increased portal venous pressure (3) increased portal venous pressure (not hypertension) often precipitates the formation of hemorrhoids
what is an NG tube used for after surgery?
(1) to decompress the stomach and limit tension on the suture line
Which assessment would the nurse perform while caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS)? (1) Quality of the cry (2) Signs of dehydration (3) Coughing up of feedings (4) Characteristics of the stool
(3) Coughing up of feedings RATIONALE: (1) HPS causes partial and then complete obstruction (2) nonprojectile vomiting will progress to projectile which quickly leads to dehydration
would the nurse document on the child's clinical record? Select all that apply. One, some, or all responses may be correct. (1) Intake and output (2) Measurement of pain (3) Tolerance of low-residue diet (4) Frequency of dressing changes (5) Presence or absence of bowel sounds
(1) Intake and output (2) Measurement of pain (5) Presence or absence of bowel sounds RATIONALE: (1) pain is assessed because a laparoscopic surgery involves insufflating the abdomen with air which will cause pain until it's reabsorbed (2) checking for bowel sounds with help determine how the child is adapting to the intestinal trauma caused by the surgery
an infant with what condition is expected to cough up feedings?
(1) tracheoesophageal fistula
A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? (1) Sodium (2) Calcium (3) Potassium (4) Phosphorus
(2) Calcium RATIONALE: (1) muscle contraction-relaxation cycle depends on adequate calcium and phosphorous ratio (2) reduction of calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms)
The nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). Which recommendations would the nurse give to the client to limit symptoms of GERD? Select all that apply. One, some, or all responses may be correct. (1) Avoid heavy lifting. (2) Lie down after eating. (3) Avoid drinking alcohol. (4) Eat small, frequent meals. (5) Increase fluid intake with meals. (6) Wear an abdominal binder or girdle.
(1) Avoid heavy lifting. (3) Avoid drinking alcohol. (4) Eat small, frequent meals. RATIONALE: (1) heavy lifting increase intra-abdominal pressure leading to gastric contents moving up through the LES (2) alcohol, caffeine, chocolate, and peppermints decrease LES pressure which allows gastric contents to move into the esophagus (3) eating small frequent meals limits about of food in the stomach which limits reflux (4) lying down should be avoided after eating because it promotes reflux (5) increasing fluids with meals increases gastric volume which could cause more reflux (6) constrictive garments increase intra-abdominal pressure and lead to more reflux
Which interventions would the nurse include in the plan of care for a client with gastroesophageal reflux disease (GERD)? Select all that apply. One, some, or all responses may be correct. (1) Encourage client to follow the prescribed treatment regimen. (2) Keep the head of the bed elevated to approximately 30 degrees. (3) Avoid placing the client in the supine position for 2 to 3 hours after a meal. (4) Instruct the client to eat six small meals a day with the last just before bedtime. (5) Instruct the client to take a proton pump inhibitor before the first meal of the day.
(1) Encourage client to follow the prescribed treatment regimen. (2) Keep the head of the bed elevated to approximately 30 degrees. (3) Avoid placing the client in the supine position for 2 to 3 hours after a meal. RATIONALE: (1) nursing care for GERD includes keep the HOB elevated, and avoiding the supine position for 2-3 hours after a meal (2) patient should avoid activities that could cause reflux at night such as eating late at night (3) proton pump inhibitors should be taken before the first meal of the day but are more common in treating peptic ulcer disease
Which of these assessments leads the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. (1) Irritability (2) High-pitched cry (3) Depressed fontanels (4) Decreased urinary output (5) Ineffective feeding behavior
(1) Irritability (2) High-pitched cry (5) Ineffective feeding behavior
The nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes would the nurse expect the parents to report? Select all that apply. One, some, or all responses may be correct. (1) Pale skin (2) Loss of hair (3) Eating less food (4) Sores in the mouth (5) Purplish spots on the skin
(1) Pale skin (3) Eating less food (5) Purplish spots on the skin - - pallor is a presenting sign of leukemia and reflects anemia because of decreased RBCs -anorexia is a presenting sign as well - may be related to enlarged lymph nodes and areas of inflammation in the intestinal tract - - decreased platelets with petechiae and bleeding (purplish spots on skin) is a presenting sign of leukemia
Which intervention would the nurse include when teaching a client about self-care after mastectomy to prevent infection and lymphedema? Select all that apply.One, some, or all responses may be correct. (1) Wear gloves when gardening. (2) Apply a compression sleeve if edema occurs. (3) Stop all activities that involve use of the affected arm. (4) Consider learning exercises for manual lymph drainage. (5) Avoid blood draws in the arm on the side of the mastectomy.
(1) Wear gloves when gardening. (2) Apply a compression sleeve if edema occurs. (4) Consider learning exercises for manual lymph drainage. (5) Avoid blood draws in the arm on the side of the mastectomy. - - wear gloves when gardening to prevent scratches that could introduce infection - - apply compression to sleeve to manage edema - - learn exercises to manually drain the lymph fluid - - avoid medical procedures in the affected arm
After a child undergoes craniotomy for the removal of a brain tumor, the nurse identifies an area of serosanguineous drainage about the size of a quarter on the child's dressing. Which action would be the immediate response by the nurse? (1) Notifying the neurosurgeon (2) Circling the area with nonabsorbable ink (3) Reinforcing the dressing with gauze pads (4) Removing the dressing to check the sutures
(2) Circling the area with nonabsorbable ink RATIONALE: (1) progression beyond markings shows that the drainage is increasing - this allows to monitor it's progression (2) not necessary to notify the surgeon because some drainage is expected (3) reinforcing the dressing would prevent you from being able to monitor the progressing of the drainage (4) only the surgeon should remove the dressing during the immediate postoperative period
The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse would include which instructions about minimizing dumping syndrome? Select all that apply. One, some, or all responses may be correct. (1) Drink fluids with meals. (2) Eat small, frequent meals. (3) Lie down for 1 hour after eating. (4) Chew food five times before swallowing. (5) Select foods that are low in fiber.
(2) Eat small, frequent meals. (3) Lie down for 1 hour after eating. RATIONALE: (1) small frequent meals keep the volume of the stomach to a minimum limiting dumping syndrome (2) lying down delays gastric emptying which will limit dumping syndrome (3) fluids should be taken between meals to decrease the volume within the stomach at one time (4) chewing a set number of times does not help solve this problem (5) high fiber, complex carbohydrates, moderate fats and high protein in small frequent meals are recommended to prevent dumping syndrome
Which action would promote psychological adjustment and early function after a teenager with a diagnosis of osteosarcoma has the affected leg amputated? (1) Allow the client to change the first dressing. (2) Help the client adjust to the temporary prosthesis. (3) Assign the client to a room with another adolescent. (4) Have the client meet with a member of a cancer survivor organization.
(2) Help the client adjust to the temporary prosthesis. RATIONALE: (1) a temporary prothesis can be attached to the cast with a metal extension immediately after surgery ➡️ will allow the adolescent to walk within several hours of surgery and help to start the adjustment process (2) first dressing change is usually done by a member of the surgical team and it is too early for the adolescent to be looking at the surgical site (3) it is also too early for the adolescent to have a cancer survivor visit - this is done later in the recovery process
Which adverse response to chemotherapy would a nurse teach a client with Hodgkin's disease to report to the health care provider? (1) Hair loss (2) Sores in the mouth (3) Moderate diarrhea after treatment (4) Nausea for 6 hours after treatment
(2) Sores in the mouth RATIONALE: (1) stomatitis is a common response but it should be reported to the provider in the case that a swish-and-swallow anesthetic solution can be prescribed to make the client more comfortable (2) moderate diarrhea is expected and isn't a concern unless dehydration results (3) nausea is expected but should be reported if it lasts more than 24 hours
Which manifestation would the nurse expect to find when assessing a client with hyperthyroidism? Select all that apply. One, some, or all responses may be correct. (1) Dry skin (2) Weight loss (3) Tachycardia (4) Restlessness (5) Constipation (6) Exophthalmos
(2) Weight loss (3) Tachycardia (4) Restlessness (6) Exophthalmos RATIONALE: (1) weight loss is caused by the increased metabolic rate initiated by hyperthyroidism (2) muscle weakness and wasting are associated with hyperthyroidism (3) increased metabolic rate is also responsible for tachycardia, palpitations, increased systolic blood pressure, dysrhythmias, restless, and insomnia (4) protrusion of the eyeballs occurs in hyperthyroidism due to peribulbar edema (5) smooth, warm, moist skin occurs with hyperthyroidism (6) increased stools and diarrhea are associated with hyperthyroidism
Which parental statement would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? Select all that apply. One, some, or all responses may be correct. (1) "My baby doesn't make eye contact." (2) "My baby seems to have a voracious appetite." (3) "My baby was able to turn from front to back by 2 months of age." (4) "I've noticed that this baby clings to me more than other children of the same age." (5) "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."
(3) "My baby was able to turn from front to back by 2 months of age." (5) "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone." RATIONALE: (1) usually able to turn from front to back at an early age due to spastic cerebral palsy - spasticity is what causes unintentional turn from front to back (2) is also considered a neurologic problem and is common associated with failure to meet developmental normals (3) anorexia or voracious appetite are not associated (4) personality traits are not related to the diagnosis of cerebral palsy
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. (1) Diplopia (2) Skin rash (3) Leg cramps (4) Tachycardia (5) Muscle weakness
(3) Leg cramps (5) Muscle weakness RATIONALE: (1) leg cramps occur due to potassium deficit (2) muscle weakness occurs with potassium deficit due to alteration in the sodium potassium pump mechanism (3) diplopia/skin rash do not indicate an electrolyte imbalance (4) bradycardia not tachycardia is associated with hypokalemia
Which condition in a client's history would lead the nurse to assess for the development of pernicious anemia? (1) Acute gastritis (2) Diabetes mellitus (3) Partial gastrectomy (4) Unhealthy dietary habits
(3) Partial gastrectomy - - Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B 12 preliminary to its absorption in the ileum). - - pernicious anemia occurs when the intrinsic factor is not produced
Which explanation would the nurse provide to a client with gastric ulcer disease who asks the nurse why the health care provider has prescribed metronidazole? (1) To augment the immune response (2) To potentiate the effect of antacids (3) To treat Helicobacter pylori infection (4) To reduce hydrochloric acid secretion
(3) To treat Helicobacter pylori infection RATIONALE: (1) Approximately two-thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function
Which step would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct. (1) Induce gastric lavage. (2) Give ipecac syrup to the client. (3) Turn the head of the client to the side. (4) Empty the mouth to clean the residue of the drug. (5) Call local poison control center before any intervention.
(3) Turn the head of the client to the side. (4) Empty the mouth to clean the residue of the drug. (5) Call local poison control center before any intervention. RATIONALE: (1) turn the head of the client to the side to avoid aspiration (2) empty the mouth if there is any remaining drug (3) if they are conscious/alert you would call the local poison control center before attempting any intervention (4) you would refrain from a gastric lavage or inducing vomiting because that could increase the risk for aspiration
Which action would a nurse take to avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer? Select all that apply. One, some, or all responses may be correct. (1) Monitor for signs of alopecia. (2) Encourage an increase in fluids. (3) Wash hands before entering the client's room. (4) Advise use of a soft toothbrush for oral hygiene. (5) Report an elevation in temperature immediately. (6) Teach the client to avoid eating raw fruits or vegetables.
(3) Wash hands before entering the client's room. (4) Advise use of a soft toothbrush for oral hygiene. (5) Report an elevation in temperature immediately. RATIONALE: (1) because bone marrow depression causes neutropenia it is essential to prevent infection which includes hand-washing before touching the client or their belongings (2) thrombocytopenia can occur with chemotherapy induced bone marrow depression so using a soft toothbrush helps prevent bleeding gums (3) any temperature elevation could indicate infection and should be immediately reported to the provider (4) increasing fluids does help with bone marrow suppression or stimulate hematopoiesis (5) kids can eat raw foots and veggies as long as they are washed off first since soil could contain disease causing microbes
On the first day after a mastectomy, the nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. How would the nurse respond to the client's question as to why she needs to do these exercises? (1) "They preserve muscle tone." (2) "They prevent joint contractures." (3) "They help us assess the extent of lymphedema." (4) "They will help stimulate peripheral circulation."
(4) "They will help stimulate peripheral circulation." - - these exercises require muscle contraction that puts pressure on blood vessels which promotes circulation - - lymphedema is assessed by measuring the circumference of the extremity not by having the client exercise
Which finding is more likely to indicate a malignancy in a 38-year-old client admitted for a biopsy of a breast lump? (1) A soft mass that is movable and nontender (2) Hard, hot, reddened areas that are tender and painful (3) Multiple bilateral lesions that are well-delineated and movable (4) A lesion in the upper outer quadrant that is poorly delineated and immobile
(4) A lesion in the upper outer quadrant that is poorly delineated and immobile - - breast malignancies are normally painless, fixed, and in the upper outer quadrant
Which clinical manifestation would the nurse expect when assessing a client with hypercalcemia? Select all that apply. One, some, or all responses may be correct. (1) Muscle tremors (2) Abdominal cramps (3) Increased peristalsis (4) Cardiac dysrhythmias (5) Hypoactive bowel sounds
(4) Cardiac dysrhythmias (5) Hypoactive bowel sounds - - Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds - - serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia.
After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube attached to negative pressure. Which would the nurse explain is the purpose of this tube? (1) Monitors the acidity of gastric secretions (2) Provides a route for liquid tube feedings when possible (3) Permits continuous decompression of the large intestine (4) Removes fluids and gas from the upper gastrointestinal tract
(4) Removes fluids and gas from the upper gastrointestinal tract RATIONALE: (1) tube is used to remove fluids and gas from the upper gastrointestinal tract which leads to improved healing of the surgical area and minimizes nausea (2) NG tube isn't used to measure the acidity of gastric secretions in this situation (3) tube feedings are contraindicated after GI surgery (4) tube is used to decompress the stomach not the large intestine
Which condition presents with elevated immunoglobulin E (IgE) levels, positive allergic skin test reactivity, and widespread skin vesicles? (1) Allergic rhinitis (2) Atopic dermatitis (3) Contact dermatitis (4) Goodpasture syndrome
(2) Atopic dermatitis - - elevated IgE levels, positive skin tests, and presence of widespread skin lesions occur with atopic dermatitis
what are clinical manifestations associated with sexual abuse?
(1) bloody underclothing (2) recurrent urinary tract infections
common manifestations of hypothyroidism
(1) dry, coarse, scaly skin because of decreased glandular secretion (2) constipation
s/s of prostate cancer
(1) dysuria (2) hesitancy (3) urinary urgency (4) leaking or dribbling
manifestations of tinea corporis
(1) erythematous, annular, ring-like scaly appearance with well-defined margins
what are multiple bilateral mobile lesions in the breast characteristics of?
(1) fibrocystic benign breast tumors
manifestations of tinea cruris
(1) fungal infection (2) well-defined scaly plaque in the groin area
recommendations for lice treatment
(1) lindane can be used but could have serious side effects (2) should not wash hair in tub or shower because this could cause the lice to be able to migrate to other spots (3) soaking combs in ammonia water can help enhance lice control (4) nits can be loosened with dilute vinegar solution (5) shampooing should be done at least once every 24-48 hours
what is allergic rhinitis?
(1) may occur yearly/seasonally (2) involves mediators (histamine and mast cells) resulting in an IgE-mediated hypersensitivity reaction
Which statement made by the student nurse about precautions to take when treating a client with open burn wounds indicates the need for further teaching? (1) "I should use nonsterile gloves when applying ointments." (2) "I should use nonsterile, disposable gloves when removing old dressings." (3) "I should wear personal protective equipment before caring for the client." (4) "I should remove personal protective equipment before leaving one client to treat another."
(1) "I should use nonsterile gloves when applying ointments." - - sterile gloves should be used
what is dumping syndrome?
(1) occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing/processing in the duodenum
potassium is part of the sodium-potassium pump which means it does what?
(1) plays a role in helping to balance the response of nerves to stimulation
The nurse is teaching dietary management to the parent of a toddler undergoing chelation therapy. Which instruction would the nurse include in the teaching? (1) Maintain a low-salt diet. (2) Ensure adequate fluid intake. (3) Avoid refined sugar and flour. (4) Offer high-calorie, low-protein foods.
(2) Ensure adequate fluid intake. - - Adequate hydration is needed because the lead complexes released during chelation therapy are excreted by the kidneys
what might a soft mobile mass in the breast indicate?
a lipoma
what is erysipelas?
a bacterial infection characterized by a red, hot, sharply demarcated plaque that is indurated and painful
hypokalmia or hyperkalemia: hyperactive bowel sounds and diarrhea
hyperkalemia
hypokalemia or hyperkalemia: dysrhythmias such as bradycardia and prolongation of the PR interval and QRS duration
hypokalemia
Which electrolyte abnormality will the nurse expect in a client who is experiencing both tingling of the extremities and tetany? (1) Hypokalemia (2) Hypocalcemia (3) Hyponatremia (4) Hypochloremia
(2) Hypocalcemia - - paresthesias (tingling of the extremities) and tetany are signs of hypocalcemia
what are s/s of hypocalcemia
-muscle tremors -abdominal cramps -increased intestinal peristalsis
s/s of perforation of the bowel include
(1) pain (2) peritonitis
manifestations of tinea unguium or onychomycosis
(1) scaliness under distal nail plate
Which is the most important safety measure for the nurse to institute immediately when a 2-year-old child has a seizure? (1) Monitoring the child's vital signs (2) Padding the side rails of the toddler's crib (3) Placing the child in the side-lying position (4) Bringing suction equipment to the bedside
(3) Placing the child in the side-lying position RATIONALE: (1) maintaining a patent airway is the priority and the side-lying position helps promote that by keeping the tongue away from the back of the pharynx and allowing saliva to flow out by gravity
