NUR 305A Final Exam

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: a.breathe with respiratory support. b.drive a vehicle with hand controls. c.ambulate with long-leg braces and crutches. d.use a powered device to handle eating utensils.

B. drive a vehicle with hand controls

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A.Notify the health care provider. B.Place the patient in a sitting position. C.Check the patient for fecal impaction. D.Check the urinary catheter for kinks or obstruction.

B. place the patient in a sitting position

This is the leading cause of death from SLE

renal failure

This is an important teaching point for a patient who will be administering interferon at home for Multiple Sclerosis.

rotate injection sites

This position is best for a patient who is experiencing appendicitis.

semi-fowler's

Patients with chronic hepatitis need to avoid this type of drink and this type of analgesic.

alcohol and acetaminophen (Tylenol)?

An ankle x-ray confirms that the patient has an ankle fracture. A fiberglass cast is applied to immobilize the ankle and allow for healing. Which are priority interventions after the cast is applied? (Select all that apply.) A.Monitor for signs of infection. B.Assess peripheral capillary refill. C.Keep the cast uncovered for air-drying over several hours. D.Ask the patient about frequency of bowel movements. E.Insert a finger between the skin and the cast to be sure the cast is not too tight.

A. monitor for signs of infection B. assess peripheral capillary refill D. ask the patient about frequency of bowel movements E. insert a finger between the skin and the cast to be sure the cast is not too tight

Why is controlling blood glucose levels important? A. High blood glucose levels increase the risk for heart disease, strokes, blindness, and kidney failure. B. High blood glucose levels increase the risk for seizure disorders, arthritis, osteoporosis, and bone fractures. C. Low blood glucose levels increase the risk for peripheral neuropathy, Alzheimer's disease, and premature aging. D. Low blood glucose levels increase the risk for obesity, pancreatitis, dehydration, and certain types of cancer.

ANS: A Rationale: Persistent high blood glucose levels cause major changes in blood vessels that lead to organ damage, serious health problems, and early death. The long-term complications of diabetes include heart attacks, strokes, and kidney failure. In addition, diabetes is the main cause of foot and leg amputations and new-onset blindness.

The patient's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone? A.Apply restraints. B.Maintain the bed in a low position. C.Sit with the patient until his wife returns. D.Place the call light in the patient's right hand.

ANS: B Restraints should not be applied until all alternate methods have been attempted. Sitting with a patient for 2 hours is impractical for the nurse. Placing a call light in the patient's right hand would not be effective because he has deficits in his right visual field and may have right field neglect.

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? A. Hematocrit B. Blood pressure C. Oxygen saturation D. Intracranial pressure

Answer: D

What are signs and symptoms of lupus?

Butterfly rash, discoid lesions, and fever.

Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a.Providing oxygen b.Encouraging carbohydrates c.Administering fluid replacement d.Teaching facts about dietary principles

C-Administering fluid replacement As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

What is a secondary effect when a child experiences decreased muscle strength, tone, and endurance from immobilization? A.Increased metabolism B.Increased venous return C.Increased cardiac output D. Decreased exercise tolerance

D: decreased exercise tolerance

What are biologic response modifiers? (interferon)

Flu- like symptoms and depression are common side effects of these class of drugs which treat chronic hepatitis

the diagnostic criteria for Acquired Immune Deficiency Syndrome (AIDS).

HIV positive, CD4 count <200 and/or the presence of an opportunistic infection

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

MAP = [(2 x diastolic)+systolic] / 3MAP=(2 x 72) + 126/3 MAP= 144+126/3 MAP=90 CPP=MAP-ICP CPP=90-18=72

The patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is your best response?

Patients must meet strict eligibility criteria for thrombolytic therapy with rtPA (recombinant tissue plasminogen activator), including giving the drug within 3 hours after the first stroke symptoms.

what is angioedema

Severe type I hypersensitivity reaction that involves the blood vessels and all layers of the skin, mucous membranes, and subcutaneous tissues in the affected area.

What is McBurney's point?

The area between the anterior iliac crest and the umbilicus in which patients with appendicitis often complain of pain.

What is epinephrine?

The first line drug for a patient experiencing anaphylaxis.

What is Crohn's disease?

This disease is characterized by diarrhea, abdominal pain (right lower quadrant), low-grade fever, and weight loss.

What is pancreatitis?

This disease is characterized by intense, boring pain that is continuous and worsened when lying in a supine position

What is acquired immune deficiency syndrome (AIDs)?

This disease is characterized by low CD4 counts, opportunistic infections, N/V/D, and night sweats.

Teaching included for a patient who is taking hydroxychloroquine for SLE.

eye exams every 6 months

what is hepatitis

inflammation of liver cells

what is pancreatitis

premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells resulting in autodigestion and fibrosis of the pancreas

•A nurse is planning care for a school-aged child experiencing respiratory acidosis. What is the sequence of events that occurs in the child's respiratory response to acidosis? Place the physiologic responses in the order in which they occur. •Increased pH •Hyperventilation •Increased CO2 elimination •Decreased blood H+ ions

•Hyperventilation •Increased CO2 elimination •Decreased blood H+ ions •Increased pH •Respiratory compensation to acidosis involves hyperventilation with increased CO2 elimination. As carbon dioxide is blown off there is a decrease in the hydrogen ions in the blood, leading to an increase in pH to expected limits.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. What is the priority assessment finding for the nurse to report? a.return of reflexes. b.bradycardia with hypoxemia. c.effects of sensory deprivation. d.fluctuations in body temperature.

B. bradycardia with hypoxemia

How is Dementia defined? 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.

Correct answer: d Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.

What is Cullen's sign?

This is a bluish discoloration around the periumbilical area seen with pancreatitis

What is rheumatoid arthritis?

This is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints.

What is Hepatitis B

This type of Hepatitis is transmitted via sexual intercourse, exposure to bodily fluids, and contaminated needles.

Long-term use of prednisone (steroid) can lead to this disease.

diabetes mellitus

These infection prevention measures are important to teach any patient who is taking any disease modifying medications.

handwashing, avoiding sick people, and avoiding large crowds

•The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? a.Acid-base balance b.Fluid balance c.Oxygen depletion d.Metabolic acidosis

•A- Acid-base balance • • •All data are within expected limits; PO2 is 80 to 100 mm Hg, PCO2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within expected limits of 80 to 100 mm Hg. With metabolic acidosis the pH is less than 7.35.

•The serum electrolyte values for a client with syndrome of inappropriate antidiuretic hormone being treated with tolvaptan indicate the following changes within the past 12 hours. Which change does the nurse report immediately to the health care provider? •A. Serum potassium decrease from 4.2 mEq/L to 3.8 mEq/L •B. Serum sodium increase from 122 mEq/L to 140 mEq/L •C. Serum calcium increase from 9.5 mg/dL to 10.2 mg/dL •D. Serum chloride decrease from 109 mEq/L to 99 mEq/L

•ANS: B •Rationale: The purpose of tolvaptan is to restore a normal sodium concentration to the blood and other extracellular fluid. In the case of SIADH, excessive amounts of antidiuretic hormone have caused more water to be absorbed, causing the serum sodium to be diluted. When tolvaptan therapy brings the serum sodium level to normal levels, it must be discontinued to prevent hypernatremia. A serum sodium of 140 mEq/L is within the normal range.

Which of the following is a priority nursing intervention for a patient with primary adrenal cortex dysfunction? A.Monitor vital signs and the patient's physiologic response to stress. B.Closely measure fluid intake and output. C.Provide emotional support during stressful situations. D.Weigh the patient daily.

•Answer: A •Rationale: The adrenal cortex makes up about 90% of the adrenal gland. Hormones secreted from the adrenal cortex are responsible for fluid and electrolyte balance, stress response, metabolism of nutrients, and emotional and sex hormone responses. Priority nursing interventions with adrenal cortex dysfunction focus on the negative feedback mechanisms of aldosterone and cortisol.

•A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure? a.Remain in the house. b.Avoid holding an infant. c.Save urine in a lead-lined container. Refrain from using a bathroom used by others.

•B- Avoid holding an infant. •Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed two to three times after use by the client. Refraining from using a bathroom used by others is not necessary.

•A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? a.An elevated pH, elevated PCO2 b.A decreased pH, elevated PCO2 c.An elevated pH, decreased PCO2 d.A decreased pH, decreased PCO2

•C- An elevated pH, decreased PCO2 • •In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated PCO2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO2 is respiratory acidosis. A decreased pH, decreased PCO2 is metabolic acidosis with some compensation.

•A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? a.Respiratory acidosis b.Respiratory alkalosis c.Metabolic acidosis d.Metabolic alkalosis

•C- Metabolic acidosis • • •The blood pH indicates acidosis; the bicarbonate (HCO3-) level is further from the expected range than is the partial pressure of carbon dioxide (Pco2), indicating a metabolic origin (losses from diarrhea), not a respiratory origin. The blood pH indicates acidosis, not alkalosis.

•A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? a.Skeletal and nervous b.Circulatory and urinary c.Respiratory and urinary d.Muscular and endocrine

•C- Respiratory and urinary •Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

This type of positioning may help decrease pain in a patient with pancreatitis.

side-lying with legs drawn to the chest

Which symptom requires immediate intervention during a hypoglycemic episode? A.Confusion B.Hunger C.Headache D.Tachycardia

Answer: A Rationale: Glucose is necessary for brain function. Confusion is a marker of severe hypoglycemia requiring immediate intervention. Irritability/anxiety, hunger, tachycardia, headache, sweating, and seizures are additional signs of hypoglycemia.

These are the precautions needed for a patient with HIV.

standard precautions

what is anaphylaxis

the most threatening example of a type 1 hypersensitivity

When should a patient with type 1 diabetes avoid exercise? A.When serum glucose is less than 150 B.During colder months C.When ketones are present in the urine D.When emotional stressors are high for the patient

Answer: C Rationale: Exercise should be avoided if ketones are present in the urine. Ketones indicate that current insulin levels are not adequate and that exercise would elevate blood glucose levels.

A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. What is the priority nursing intervention ? A.Recommend allergy testing. B.Provide a latex-free environment. C.Use only powder-free latex gloves. D.Limit the use of latex products as much as possible.

B. provide a latex-free environment

This is the most important primary prevention for healthy immunity.

vaccinations

What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? A.Dehydration B.Aspiration pneumonia C.Constipation D.Weight loss

Answer: B Rationale: Cranial nerves IX (glossopharyngeal) and X (vagal) assist with the patient's ability to swallow. Aspiration pneumonia is a serious risk associated with dysfunction of these cranial nerves. Other concerns include dehydration, constipation, and inadequate nutrition.

A nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply. a.Leg ulcers b.Loss of visual acuity c.Increased creatinine clearance d.Prolonged capillary refill in the toes e.Decreased sensation in the lower extremities

A, B, D, E Ulcers of the legs are a common response to the microvascular and macrovascular changes associated with diabetes. Retinopathy, damage to the microvascular system of the retina (e.g., edema, exudate, and local hemorrhage), occurs as a result of occlusion of the small vessels, causing microaneurysms in the capillary walls. Macrovascular changes in the distal capillary beds interfere with blood flow to the distal extremities. Decreased sensation in the lower extremities is a complication of diabetes. Consistent hyperglycemia causes a buildup of sorbitol and fructose in the nerves that cause impairment via an unknown process. Creatinine clearance decreases, not increases, as renal function deteriorates in response to microvascular damage to the small blood vessels that supply the glomeruli.

The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? a.Insulin needs will increase during the second trimester. b.Insulin needs will decrease during the second trimester. c.Insulin needs will not change during the second trimester. d.Insulin will be switched to an oral antidiabetic medication during the second trimester.

A- Insulin needs will increase during the second trimester. The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks of gestation. The use of oral antidiabetes agents is currently not recommended by the American Diabetes Association for use during pregnancy.

A 15 year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The most appropriate nursing interventions for this adolescent are (select all that apply) A.monitoring neurologic status. B.administering corticosteroids. C.monitoring for respiratory complications. D.discussing long-term care issues with the family. E.monitoring and maintaining hemodynamic status.

A. monitoring neurologic status B. administer corticosteroids C. monitoring for respiratory complications E. monitoring and maintaining hemodynamic status

To control the patient's pain, which order would you expect from the provider? A.Morphine 1 to 2 mg IV B.Meperidine 50 mg IM C.Acetaminophen 650 mg by mouth D.Apply ice packs to the right ankle

A. morphine 1 to 2 mg IV

A middle-aged male patient has a tight cast on his left lower leg. An early assessment variable requiring further evaluation for compartment syndrome would be: A.Pain more intense than that of the injury itself B.Tingling sensation C.Diminished pulses D.Discoloration of toes

A. pain more intense than that of the injury itself

A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend? A.Teach the child to do self-catheterization. B.Teach the child appropriate bladder control. C.Continue having the parents do the catheterization. D.Encourage the family to consider urinary diversion.

A. teach the child to do self-catheterization

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? A. "This type of monitoring system is complex and highly skilled staff are needed." B. "The monitoring system helps show whether blood flow to the brain is adequate." C. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." D. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

Answer: B

The patient needs assistance with feeding, but can swallow well. To whom would it be best to delegate this responsibility? A.Licensed practical nurse B.Certified nursing assistant C.Hospital volunteer D.Student nurse doing first patient care experience

ANS: B Feeding patients falls within the scope of practice for a CNA.

Which statement made by the client during nutritional counseling indicates to the nurse that the client with diabetes type 1 correctly understands his or her nutritional needs? A. "If I completely eliminate carbohydrates from my diet, I will not need to take insulin." B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." C. "My intake of protein in terms of grams and calories should be the same as my intake of carbohydrate." D. "My intake of unsaturated fats in terms of grams and calories should be the same as my intake of protein."

ANS: B Rationale: Carbohydrates are the main fuel for the human cellular engine and the substance most commonly used to make ATP. Clients who have diabetes should never consume less than 130 g of carbohydrate per day (the percentage of total calories needed is determined for each client) . Protein intake should range between 15% and 30% of total caloric intake per day.

Which statement by a client about preventing stroke indicates a need for further teaching by the nurse? A. "I am going to join Alcoholics Anonymous to help me stop drinking." B. "I only smoke cigars, which is better than smoking cigarettes." C. "I need to walk at least 5 days a week to increase my exercise level." D. "I need to lose at least 30 pounds to get my BMI into normal range."

ANS: B Rationale: Smoking is a modifiable risk factor for stroke. The nurse should instruct the client that smoking is a risk factor, regardless of whether it is cigarettes or cigars. Alcohol consumption is a modifiable risk factor for stroke, and the nurse should support and reinforce the client's decision to join a support group such as Alcoholics Anonymous to assist him or her to stop drinking. Increasing physical activity can decrease a client's risk for stroke and should be encouraged. Weight loss is a modifiable risk factor; weight loss and getting the client's BMI into a normal range is a positive step toward stroke prevention.

The nurse is caring for a patient treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse? A. Client's blood pressure is 144/90. B. Client is having epistaxis. C. Client ate only half of the last meal. D. Client continues to be drowsy.

ANS: B Rationale: rtPA [Retavase] is a thrombolytic used for the treatment of acute ischemic stroke. Thrombolytics activate plasminogen, which degrades the thrombus by breaking down fibrin. Clients must be monitored for bleeding; if bleeding occurs, the nurse should stop the infusion immediately to prevent hemorrhage.

An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would you expect? (Select all that apply) A.Disorientation to time, place, and person B.Inability to discriminate words and letters C.Constant smiling D.Intellectual impairment E.Neglect of left visual field F.Deficits in the right visual field

ANS: B, D, F Patients experiencing a left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, and deficits in the right visual field. Disorientation, constant smiling, and neglect of left visual field are manifestation of a right hemisphere stroke.

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as A. 9. B. 11. C. 13. D. 15.

Answer: B 3 points for eye opening to voice 3 points for inappropriate words 5 points for localizing to noxious stimuli

The client newly diagnosed with type 1 diabetes asks why insulin is given only by injection and not as an oral drug. What is the nurse's best response? A. "Injected insulin works faster than oral drugs to lower blood glucose levels." B. "Oral insulin is so weak that it would require very high dosages to be effective." C. "Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes." D. "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."

ANS: C Rationale: Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.

A client with a confirmed acute ischemic stroke is admitted to the medical unit after evaluation in the emergency department. What is the nurse's priority action on admission? A. Ask the nursing technician to weigh the client and record it. B. Consult with the physical therapist about the client's rehabilitative care. C. Keep the client NPO until the swallowing assessment is complete. D. Give warfarin and check activated thromboplastin levels.

ANS: C Rationale: Clients who have experienced a stroke may develop swallowing difficulties and are at risk for choking and aspiration. The client should be maintained on NPO status until a swallowing evaluation is performed by the speech therapist. Although weighing the client and consulting with the rehabilitation team are important, these actions are not the priority at this time. Although previously widely used, anticoagulants such as warfarin are controversial and are not considered current best practice by the American Stroke Association for acute ischemic stroke or for preventing future strokes because of the risk of bleeding.

A client with type 2 diabetes who also has heart failure is prescribed metformin extended-release (Glucophage XR) once daily. On assessment, the nurse finds that the client now has muscle aches, drowsiness, low blood pressure, and a slow, irregular heartbeat. What is the nurse's best action? A. Assess the client's blood glucose level and prepare to administer IV glucose. B. Reassure the client that these symptoms are normal effects of this drug. C. Hold the dose and notify the prescriber immediately. D. Administer the drug at bedtime to prevent falls.

ANS: C Rationale: Muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat are symptoms of lactic acidosis, an adverse reaction to metformin. The drug should be stopped and the prescriber notified so steps can be taken to reduce the client's acidosis.

The client newly diagnosed with diabetes asks why he is always so thirsty. What is the nurse's best response? A. "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." B. "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." C. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." D. "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost

ANS: C Rationale: The movement of glucose into cells is impaired, and the resulting high blood glucose levels increase the osmolarity of the blood. This increased osmolarity stimulates the osmoreceptors in the hypothalamus, triggering the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.

The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A.Provide perineal care B.Assess for gag reflex C.Elevate the head of bed D.Perform a linen and gown change

ANS: C The airway must be protected. Elevating the head of the bed prevents swallowing concerns and allows for an open airway. The patient should then be assessed for a gag reflex, perineal care should be provided, and linens changed

The client newly diagnosed with type 2 diabetes asks how diabetes type 1 and diabetes type 2 are different. What is the nurse's best response? A. "Diabetes type 1 develops in people younger than 40 years and diabetes type 2 develops only in older people." B. "Diabetes type 2 develops in people younger than 40 years and diabetes type 1 develops only in older people." C. "Patients with type 1 diabetes are at higher risk for obesity and heart disease, whereas patients with type 2 diabetes are at higher risk for strokes." D. "Patients with type 1 diabetes produce no insulin and patients with type 2 diabetes produce insulin but their insulin receptors are not very sensitive to it."

ANS: D Rationale: The main problem with type 1 diabetes is that the person can no longer make insulin. Without insulin, the client's blood glucose level becomes very high, but glucose cannot enter many cells. Clients with type 1 diabetes must use insulin daily for the rest of their lives or receive a pancreas transplant. With type 2 diabetes, the person still has beta cells that make some insulin. In fact, some people with type 2 diabetes have normal levels of insulin; however, the insulin receptors are not very sensitive to it. As a result, insulin does not bind as tightly to its receptors as it should, and less glucose moves from the blood into the cells.

•A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term infant on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with fetal alcohol syndrome? A.Length of 19 inches B.Abnormal palmar creases C.Birth weight of 6 lb.14 oz. D. Head circumference appropriate for gestational age

Answer B

A patient with Alzheimer's disease has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for the patient is to: 1. Let the patient know what behavior is socially appropriate. 2. Assist the patient with all self-care to maintain self-esteem. 3. Maintain familiar routines of sleep, meals, drug administration, and activities. 4. At every encounter with the patient, ask the day, time, and place to promote orientation.

Answer: 3 Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD can be detected. The nurse describes early warning signs of AD, including: 1. Forgetting a colleague's name at a party. 2. Repeatedly misplacing car keys or a wallet. 3. Leaving a pot on the stove that boils dry and burns. 4. Having no memory of preparing a meal and forgetting to serve or eat it.

Answer: 4 Rationale: Memory loss that affects job skills: Frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong. This type of memory loss goes beyond forgetting an assignment, a colleague's name, a deadline, or a phone number. Difficulty performing familiar tasks: It is not abnormal for most people to become distracted and to forget something (e.g., leave something on the stove too long). People with Alzheimer's disease (AD) may cook a meal but then forget not only to serve it but also that they made it. Misplacing things: For many individuals, temporarily misplacing keys, purses, or wallets is a normal albeit frustrating event. Persons with AD may put items in inappropriate places (e.g., eating utensils in clothing drawers) but have no memory of how they got there.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Keep the head of the bed elevated to 30 degrees. B. Position the patient with the knees and hips flexed. C. Encourage coughing and deep breathing to improve oxygenation. D. Cluster nursing interventions to provide uninterrupted rest periods.

Answer: A

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? A. Blood pressure 156/60, pulse 55, respirations 12 B. Blood pressure 130/72, pulse 90, respirations 32 C. Blood pressure 148/78, pulse 112, respirations 28 D. Blood pressure 110/70, pulse 120, respirations 30

Answer: A Cushing's triad-hypertension (widening pulse pressure), bradycardia, bradypnea Pulse pressure is the difference between the systolic and diastolic pressure readings.

Which symptom is the earliest indicator of increased intracranial pressure? A.Increased pupil size B.Elevated blood pressure C.Agitation and confusion D.Nausea and vomiting

Answer: C Rationale: The first sign of increased intracranial pressure (ICP) is a declining or changing level of consciousness (LOC). Patients may be agitated and slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea and vomiting, and pupillary response occur as ICP increases.

•A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? A.Allow the newborn to establish own sleep-rest pattern B.Maintain the newborn in a brightly lit area of the nursery C.Encourage frequent handling of the newborn by staff and parents D.Monitor the newborn's response to feedings and weight gain patterns.

Answer: D

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as A. flexion withdrawal. B. localization of pain. C. decorticate posturing. D. decerebrate posturing.

Answer: Decorticate arms are adducted and flexed

The nurse is caring for a patient with type 1 diabetes mellitus who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? a. Hypokalemia b. Fluid overload c. Hypoglycemia d. Hyperphosphatemia

Answer: a Rationale: Electrolytes are depleted in diabetic ketoacidosis. Osmotic diuresis occurs with depletion of sodium, potassium, chloride, magnesium, and phosphate levels. A patient with diabetic ketoacidosis will be dehydrated (fluid volume deficit), and blood glucose levels would be elevated (hyperglycemia).

A patient with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. It is most important that the nurse advise the patient to a. Withhold the regular dose of insulin. b. Drink cool fluids with high glucose content. c. Check the blood glucose level every 2 to 4 hours. d. Use a less strenuous form of exercise than usual until the illness resolves.

Answer: c Rationale: If a person with type 1 diabetes mellitus is ill, he or she should test blood glucose levels at least at 2- to 4-hour intervals to determine the effects of this stressor on the blood glucose level.

The nurse plans a class for patients who have newly diagnosed type 2 diabetes mellitus. Which goals is most appropriate? a. Make all patients responsible for the management of their disease. b. Involve the family and significant others in the care of these patients. c. Enable the patients to become active participants in the management of their disease. d. Provide the patients with as much information as soon as possible to prevent complications.

Answer: c Rationale: The goal of diabetes education is to enable the patient to become the most active participant in his or her own care.

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L). Which statement by the nurse is best? a. "The laboratory test result is positive for type 2 diabetes." b. "You will develop type 2 diabetes within 5 years." c. "The test reis normal, and diabetes is not a problem." d. "You are at increased risk for developing diabetes."

Answer: d Rationale: Impaired fasting glucose (fasting blood glucose level between 100 and 125 mg/dL) and impaired glucose tolerance (2-hour plasma glucose level between 140 and 199 mg/dL) represent an intermediate stage between normal glucose homeostasis and diabetes. This stage is called prediabetes, and patients are at increased risk for the development of type 2 diabetes.

An adolescent with type 1 diabetes is brought to the emergency department in ketoacidosis. The adolescent admits to not adhering to the diabetic regimen. What can the nurse do to help the adolescent become more accepting of the diabetic regimen? a.Determine what the adolescent has been taught about diabetes. b.Encourage the adolescent to express feelings about having diabetes. c.Explain to the parents that it is their responsibility to demonstrate their acceptance. d.Provide the family with printed materials about the consequences of ineffectively controlled diabetes.

B- Encourage the adolescent to express feelings about having diabetes. Psychosociocultural factors related to chronic illness often affect individual adherence to a medical regimen, particularly in an adolescent. These feelings must be explored and addressed before there can be acceptance of the treatment plan. The adolescent's feelings should be explored before it is determined what the adolescent knows about diabetes. Although it is important for the parents to demonstrate acceptance, adolescents need control and therefore the teaching must begin with the adolescent. Printed materials may be helpful later, but scare tactics rarely prompt changes with any lasting benefit.

An adolescent with type 1 diabetes is brought to the emergency department unconscious. The blood glucose level is found to be 742 mg/dL. What clinical manifestation does the nurse expect the adolescent to exhibit during the initial assessment? a.Pyrexia b.Hyperpnea c.Bradycardia d.Hypertension

B- Hyperpnea Hyperpnea (Kussmaul respirations) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism of metabolic acidosis. An increased temperature will be present only if an infection is present. Tachycardia, not bradycardia, results from the hypovolemia of dehydration associated with hyperglycemia. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.

A woman who has gestational diabetes gives birth at term to a large-for-gestational age (LGA) infant weighing 9 lb 6 oz (4250 g). For what complication should the newborn be monitored? a.Anemia b.Hypoglycemia c.Increased calcium d.Meconium aspiration

B- Hypoglycemia Infants of mothers with gestational diabetes (IGDMs) are prone to hypoglycemia because of their hyperinsulinemia, which develops in response to the increased maternal glucose level. Infants of diabetic mothers (IDMs) are prone to polycythemia, not anemia. IGDMs are prone to hypocalcemia, not hypercalcemia. Meconium aspiration is more common in postterm newborns.

The nurse determines that teaching about management of osteoarthritis of the feet and hands has been effective with what patient statement? A."I will be careful to avoid crowds and people with infections." B."I can use heat to relieve the stiffness when I wake up in the morning." C."I should exercise my hands every day, especially if they are painful and inflamed." D."I should avoid the use of glucosamine as it has been shown to have no therapeutic value."

B. "i can use heat to relieve the stiffness when i wake up in the morning"

A patient has sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. Which statement is true about the fracture? A. Healing is usually delayed in this type of fracture B. Bone growth can be affected by this type of fracture C. This is an unusual fracture site in young children D. This type of fracture is inconsistent with a fall

B. bone growth can be affected by this type of fracture

Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is your best response?

Before the patient is given any liquids, food, or medications, he must be screened for the ability to swallow. Also his gag and cough reflexes must be checked. After he has his swallowing screen and it is determined that he can tolerate liquids or food without aspirating, fluids and food will be provided.

A nurse is caring for an 11-year-old child with type 1 diabetes. Two hours after breakfast the child becomes pale, diaphoretic, and shaky. What action should the nurse take? a.Notifying the practitioner b.Administering supplemental insulin c.Obtaining a current blood glucose level d.Giving orange juice with a slice of bread

C- Obtaining a current blood glucose level Although the child is demonstrating signs and symptoms of hypoglycemia, the blood glucose level must be determined before therapy can be instituted. The practitioner should be notified after the blood glucose level is known and after emergency intervention has been implemented, if required. Administering insulin will exacerbate the hypoglycemia and endanger the child. If hypoglycemia is present, low-fat milk is preferred as a simple carbohydrate and a slice of bread with peanut butter provides complex carbohydrates.

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? a.A heart rate of 92 b.A reddened area over the patient's coccyx c.Marked perspiration on the patient's face and arms d.A light inspiratory wheeze on auscultation of the lungs

C. marked perspiration on the patient's face and arms

A 54-year-old man presents to the ED with a deformed right ankle. He states that he was jogging close to the edge of a hillside, and that he tripped and fell down the hill. There are no openings in the skin. A pulse cannot be obtained by touch to the right foot, which is pale and cool to palpation. The patient rates his pain as an "8" on a 0-to-10 scale. Which is the priority nursing action at this time? A.Administer pain medication. B.Prepare for reduction. C.Obtain a Doppler of the right foot pulse. D.Notify the physician of the lack of a pulse in the right foot.

C. obtain a doppler of the right foot pulse

The patient's ankle heals and his cast is removed. Which teaching point would you include for care of his ankle after the cast is removed? A.Keep your ankle in a low position to facilitate perfusion to the healed bone. B.Exercise vigorously at least 3 times a day as directed by the physical therapist. C.Wear a support stocking to prevent lower extremity swelling. D.Scrub your lower leg and ankle to remove dead, scaly skin.

C. wear a support stocking to prevent lower extremity swelling

What is a major goal of treatment for the patient with AD? 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.

Correct answer: a Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

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

Correct answer: d Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used in the evaluation of patients with dementia. A psychologic evaluation is also indicated to determine the presence of depression.

A 9-year-old child who has had type 1 diabetes for several years is brought to the emergency department of a community hospital. The child is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. What blood pH and glucose level does the nurse expect the laboratory tests to reveal? a.7.20 and 60 mg/dL b.7.50 and 60 mg/dL c.7.50 and 460 mg/dL d.7.20 and 460 mg/dL

D- 7.20 and 460 mg/dL A pH of 7.20 and blood glucose level of 460 mg/dL are expected values in ketoacidosis; the pH of 7.20 indicates acidosis (metabolic) and the blood glucose level of 460 mg/dL is higher than the expected range of 90 to 110 mg/dL. Although the blood pH of 7.20 indicates acidosis, the blood glucose of 60 mg/dL is less than the expected range of 90 to 110 mg/dL, indicating hypoglycemia rather than hyperglycemia. Neither the pH of 7.50 nor the blood glucose value of 60 mg/dL is expected with ketoacidosis; with ketoacidosis, the pH is decreased and the blood glucose level is increased. Although the blood glucose is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? a.Fluid loss b.Glycosuria c.Increased blood glucose level d.Kussmaul respirations

D- Kussmaul respirations Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.

The patient tells the nurse that he was jogging to train for a marathon, which has been a lifelong goal. He asks, "Will I ever be able to run a marathon now?" What is the correct nursing response? A."Of course; after this heals, you will be fine." B."The doctor will be able to tell you that." C."It is unlikely that your ankle will regain the necessary strength." D."It sounds like you are concerned that you may not be able to achieve your goal."

D. "it sounds like you are concerned that you may not be able to achieve your goal"

What is the priority assessment/intervention when caring for a child with myelomeningocele in the preoperative stage? A.Place the child on one side to decrease pressure on the spinal cord. B.Apply a heat lamp to facilitate drying and toughening of the sac. C.Keep the skin clean and dry to prevent irritation from diarrheal stools. D.Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

D. measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus

Patients with RA should place their joints in this position.

neutral position

•A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? a.7.20 b.7.35 c.7.45 7.48

•A- 7.20 • •The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.

•A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet? a.Add extra salt to food b.Limit intake to 1200 calories c.Omit protein foods at each meal d.Restrict the daily intake of fluids to 1 L

•A- Add extra salt to food • •Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to develop hyponatremia. Therefore, the addition of salt to the diet is advised. Intake of calories and fluid is determined on an individual basis, not because the client has Addison disease. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism. Fluids are not restricted for clients with Addison disease.

•An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis

•A- Metabolic acidosis • •A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis, not alkalosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

•After receiving levothyroxine for 3 months for congenital hypothyroidism an infant is brought to the pediatric clinic for a checkup. What does the mother tell the nurse about her baby that indicates that the drug is effective? a.The infant's stools are soft. b.The skin is cool to the touch. c.The baby's fine tremor has ceased. d.The baby's activity level has decreased.

•A- The infant's stools are soft. • •Because levothyroxine (Synthroid) increases the basal metabolic rate, an absence of constipation is a therapeutic response to the medication. Cool skin is a clinical sign of hypothyroidism related to a slow basal metabolic rate. Fine hand tremor is related to hyperthyroidism and is not present in an infant with hypothyroidism, even one whose condition is being stabilized with levothyroxine. Decreased activity is a sign that the levothyroxine has not been effective.

•Which precaution is most important for the nurse to teach a client who is prescribed oral corticosteroids for hormone replacement therapy after a unilateral adrenalectomy? •A. "Do not stop taking this drug without consulting your prescriber." •B. "Avoid crowds and people who are ill." •C. "Be sure to take this drug with food." •D. "Reduce your salt intake."

•ANS: A •Rationale: All of the choices are precautions that the nurse should teach the client taking an oral corticosteroid chronically. However, the most critical precaution is to not stop taking the drug because chronic corticosteroid use causes atrophy of the adrenal glands. With adrenal gland atrophy, the person no longer makes his or her own normal levels of corticosteroids, which are essential for life. Long-term steroid use should never be suddenly stopped.

•Which client assessment finding indicates to the nurse the need to assess further for a possible endocrine problem? •A. A history of taking oral contraceptives for more than 2 years •B. A weight loss of 15 lbs in the past 6 weeks without dieting •C. The client's father's diagnosis of prostate cancer •D. A recent need for corrective lenses

•ANS: B •Rationale: An unintentional weight loss in excess of 5 lbs is significant. It indicates an increase in metabolic rate or a problem with excessive fluid loss, either of which could be associated with an endocrine disorder. Taking oral contraceptives for more than 2 years is not associated with endocrine problems. The father's diagnosis of prostate cancer may increase the client's risk or predisposition to cancer but not to endocrine problems. Although a need for corrective lenses can be caused by an endocrine problem, it is not the common reason for this need.

Which response in a client with diabetes insipidus indicates to the nurse that another dose of desmopressin acetate (DDAVP) is needed? A. Urine output and specific gravity are increased. B. Urine output is increased and urine specific gravity is decreased. C. Urine output and specific gravity are decreased. D. Urine output is decreased and urine specific gravity is increased.

•ANS: B •Rationale: Diabetes insipidus (DI) is caused by a failure to secrete sufficient amounts of antidiuretic hormone (ADH) to maintain blood osmolarity and prevent hyperosmolar blood and other extracellular fluid. ADH increases the amount of water reabsorbed from urine and returned to systemic circulation. Without adequate amounts of ADH, more water is excreted in the urine, increasing urine volume and decreasing urine specific gravity. DDAVP has a similar action to ADH but it is temporary. When urine volume increases and the specific gravity decreases, more drug is needed.

Which is a possible outcome for the patient experiencing an age-related decrease in antidiuretic hormone? A.Constipation, lethargy, and dry skin B.Greater-than-ideal body weight C.Diluted urine and dehydration D.Yeast infection and polydipsia

•ANS: C •Rationale: These are symptoms that result from an age-related decrease in antidiuretic hormone. The other symptoms listed are not.

A patient is diagnosed with small cell lung cancer. Which endocrine condition is consistent with this diagnosis? A.Syndrome of inappropriate antidiuretic hormone (SIADH) B.Diabetes insipidus (DI) C.Cushing's syndrome D.Adrenal crisis

•Answer: A •Rationale: Cancer (especially lung cancers) increases the risk of the patient developing SIADH. Other risk factors include recent head trauma, cerebrovascular disease, and tuberculosis or other pulmonary disease. A review of past and current medications is also important in searching for the cause of SIADH.

Which patient with Cushing's disease is at greatest risk for developing heart failure? A.42-year-old with a serum creatinine level of 3.7 mg/dL B.59-year-old with a history of hypertension C.32-year-old with a history of hepatitis B infection D.60-year-old with pneumonia

•Answer: A •Rationale: The 42-year-old patient has compromised kidney function evidenced by an elevated serum creatinine level. Preventing fluid overload that may quickly lead to pulmonary edema and heart failure is a primary concern for patients with Cushing's disease. Any patient with Cushing's disease is at risk for developing fluid overload, regardless of age. However, the older adult or one who has coexisting cardiac problems, kidney problems, pulmonary problems, or liver problems, is at greater risk.

A postoperative plan of care for a patient after a total thyroidectomy should include which intervention? A.Avoiding extending the patient's neck B.Administering oxygen via nasal cannula as needed C.Assessing the patient's voice once per shift D.Encouraging the patient to be out of bed in a chair

•Answer: A •Rationale: The nurse should avoid extending the patient's neck to decrease tension on the suture line. The air in the patient's room should be humidified to promote easier respirations and thin respiratory secretions. The patient's voice should be assessed for changes every 2 hours. Sandbags or pillows should be used to support the patient's head or neck, and the patient should be placed in a semi-Fowler's position.

Which assessment finding should trigger a more detailed assessment of the patient's endocrine system? A.Weight gain B.Changes in hair texture and distribution C.Fatigue D.Poor peripheral pulses

•Answer: B •Rationale: Changes in physical appearance can reflect an endocrine problem. Obvious changes identified during the physical assessment include hair texture and distribution, facial contours and eye protrusion, voice quality, body proportions, and secondary sexual characteristics. Changes in weight and fatigue may also be associated with endocrine disorders as well as other conditions. Poor peripheral pulses are more likely associated with cardiovascular diseases.

A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because a.Potassium is returned to extracellular fluid when metabolic acidosis is corrected. b.Hyperkalemia causes an alkalosis that results in potassium being shifted into the cells. c.Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells. d.In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate.

•Answer: C •Rationale: Changes in pH (hydrogen ion concentration) will affect potassium balance. In acidosis, hydrogen ions accumulate in the intracellular fluid (ICF), and potassium shifts out of the cell to the extracellular fluid to maintain a balance of cations across the cell membrane. In alkalosis, ICF levels of hydrogen diminish, and potassium shifts into the cell. If a deficit of H+ occurs in the extracellular fluid, potassium will shift into the cell. Acidosis is associated with hyperkalemia, and alkalosis is associated with hypokalemia.

What parameter should be critically evaluated when providing care to a patient with Graves' disease? A.Irregular heart rate and rhythm B.Elevated blood pressure C.Elevated temperature D.Change in respiratory rate

•Answer: C •Rationale: Increases in temperature may indicate a rapid worsening of the patient's condition and the onset of "thyroid storm." Further evaluation of cardiovascular status is warranted.

•The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis? a.A patient with a traumatic brain injury b.A patient with type 1 diabetes mellitus c.A patient with acute respiratory failure d.A patient with nasogastric tube suction

•Answer: D •The patient with NG tube is losing gastric acid and therefore is at risk for metabolic alkalosis.

A patient has the following ABG results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to have • a.Muscle cramping b.Warm, flushed skin c.Respiratory rate of 36 d.Blood pressure of 94/52

•Answer: a •Rationale: The patient is experiencing metabolic alkalosis (elevated pH and elevated HCO3). Clinical manifestations of metabolic alkalosis include hypertonic muscles and cramping and reduced respiratory rate. Hypotension and warm, flushed skin may occur with respiratory acidosis.

The nurse is caring for a female patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed? a. The patient complains of increased thirst. b. The patient reports a sore throat when swallowing. c. The patient supports her head when moving in bed. d. The patient makes harsh, vibratory sounds when breathing.

•Answer: d •Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.

•To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? a.A change in the respiratory rate b.A tingling sensation in the hands c.Periodic changes in the fetal heart rate d.A pulse oximetry reading of less than 98%

•B- A tingling sensation in the hands •The presence of a tingling sensation in the hands indicates respiratory alkalosis due to a decrease in carbon dioxide. A change in respiratory rate is incorrect because although such a change may contribute to respiratory alkalosis, it is not evidence of an increase in pH. In the presence of maternal respiratory alkalosis, chemical changes in maternal erythrocytes facilitate oxygen release to the fetus, which assists in maintaining a normal fetal heart rate. A pulse oximetry reading of 98% is incorrect because this is a normal finding.

•A client's parathyroid glands are removed with total thyroidectomy surgery. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? a.Constipation b.Muscle spasms c.Hypoactive reflexes d.Increased specific gravity

•B- Muscle spasms • •Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia. Hypoactive reflexes are signs of hypercalcemia. Increased specific gravity is a sign of fluid volume deficit.

•A nurse administers the drug desmopressin acetate (DDAVP) to a client with diabetes insipidus. What should the nurse monitor to evaluate the effectiveness of the drug? a.Arterial blood pH b.Intake and output c.Fasting serum glucose Pulse and respiratory rates

•B-Intake and output • •DDAVP replaces antidiuretic hormone (ADH), facilitating reabsorption of water and consequent return of a balanced fluid intake and urinary output. The mechanisms that regulate pH are not affected. DDAVP does not alter serum glucose levels; diabetes mellitus, not diabetes insipidus, results in hyperglycemia. Although correction of tachycardia is consistent with correction of dehydration, the client is not dehydrated if the fluid intake is adequate; respirations are unaffected.

•What is a nursing priority to prevent complications in clients with respiratory acidosis? a.Assessing the nail beds b.Listening to breath sounds c.Monitoring breathing status d.Checking muscle contractions

•C- Monitoring breathing status • •The nursing priority for preventing complications when caring for clients with respiratory acidosis is to monitor breathing status hourly and intervening changes. Assessing the nail beds for cyanosis, which is usually a late finding in acidosis, is not a priority intervention. Listening to breath sounds and assessing how easily air moves into and out of the lungs can be a second priority intervention. Checking muscle contractions in the neck region is a later priority intervention.

•A nurse in the pediatric unit is reviewing the arterial blood gas values of a 4-year-old child recovering from severe dehydration. Which results most accurately reflect the child's recovery? a.pH 7.50, Po2 85 mm Hg,Pco2 35 mm Hg b.pH 7.25, Po2 60 mm Hg, Pco2 50 mm Hg c.pH 7.40, Po2 85 mm Hg, Pco2 40 mm Hg d.pH 7.45, Po2 70 mm Hg, Pco2 25 mm Hg

•C- pH 7.40, Po2 85 mm Hg, Pco2 40 mm Hg • • •Expected arterial blood gas values are pH of 7.35 to 7.45, Po2 of 83 to 108 mm Hg, and Pco2 of 35 to 45 mm Hg; thus these gases are within normal limits. A pH of 7.5 indicates alkalosis. A pH of 7.25 indicates acidosis, a Po2 of 60 mm Hg indicates hypoxia, and a Pco2 of 50 mm Hg indicates hypercapnia. A Po2 of 70 mm Hg indicates hypoxia, and a Pco2 of 25 indicates hypocapnia.

•One week after beginning anti-thyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis (thyroid storm). The nurse determines that the most important intervention for this client is: a.Limiting fluid intake b.Observing for an exaggerated response to sedatives c.Treating the associated hyperglycemia and ketoacidosis d.Reducing body temperature and heart rate

•D- Reducing body temperature and heart rate •Immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. The need is for an increase, not decrease, in fluid intake to compensate for that lost because of the high metabolic rate. A response to sedatives is not likely because drugs are metabolized more rapidly with thyrotoxic crisis; there is a danger of exaggerated effects of the drug with hypothyroidism. Clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate.