NURS 405: Med Surg II Presentation NCLEX Questions

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply) A) Diuretic B) Beta-blocking agent C) Opioid analgesic D) Lactulose (Cephulac) D) Sedative

*A* *B* *D* Diuretic, Beta Blocking agent, Lactulose Rationale: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. Lactulose is prescribed to aid in the elimination of ammonia in the stool.

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A) Initiate contact precautions B) Weigh client weekly C) Measure abdominal girth 7.5cm (3 in) above the umbilicus D) Provide a high-calorie, high-carbohydrate diet

*D* Provide a high-calorie, high carbohydrate diet Rationale: a high calorie-high carbohydrate dies is recommended for clients who have hepatitis B because it meets their specific nutritional needs

A nurse is preparing a plan of care for a client with DM who has hyperglycemia. The priority nursing diagnosis would be: A) High risk for deficient fluid volume B) Deficient knowledge: disease process and treatment C) Imbalanced nutrition: less than body requirement D) Disabled family coping: compromised

*A* High risk for deficient fluid volume Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are no related specifically to the subject of the question.

Which of the following are age-related changes affecting the male reproductive system? A) Plasma testosterone levels decrease B) Prostate secretion increases C) Patency increases D) Testes become soft

*A* Plasma testosterone levels decrease Rationale: Changes in gonadal function include a decline in plasma testosterone levels and reduced production of progesterone. The testes become smaller and more firm

A client is admitted with the diagnosis of testicular cancer. Which of the following factors in the client's history would be associated with the disease? A) Undescended testes B) Sexual relations at an early age C) Epididymitis D) Seminal vesiculitis

*A* Undescended testes Rationale: A history of undescended testes or cryptorchidism is a known risk factor. Sexual relations at an early age, epididymitis, and seminal vesiculitis are not risk factors

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate (TURP). In addition to balloon inflation, the nurse is aware that the functions of the three lumens include: A) Continuous inflow and outflow of irrigation solution B) Intermittent inflow and continuous outflow of irrigation solution C) Continuous inflow and intermittent outflow of irrigation solution D) Intermittent flow of irrigation solution and prevention of hemorrhage

*A* Continuous inflow and outflow of irrigation solution Rationale: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution

A nurse is caring for a client who was recently admitted to the emergency department following a head on MVA. Client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A) Keep neck stabilized B) Insert NG tube C) Monitor pulse and BP frequently D) Establish IV access and start fluid replacement

*A* Keep neck stabilized Rationale: the greatest risk to the client if permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out

A nurse working in a provider's office is assessing a client who has a severe sunburn. Which of the following is the proper classification of this burn? A) Superficial B) Superficial partial-thickness C) Deep partial-thickness D) Full thickness

*A* Superficial Rationale: A sunburn is superficial because only the top layer of skin is damaged.

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? A) Use the unaffected arm for blood pressure measurements. B) Inject heparin into the cannula each shift. C) Draw blood from the cannula for routine laboratory work. D) Percuss the cannula for bruits each shift.

*A* Use the unaffected arm for blood pressure measurements. Rationale: a patient with a dialysis graft or fistula in their arm should not have any needlesticks or blood pressures taken on that arm, as it could damage the fistula or graft, or cause a clot to form within it.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: A) Water and sodium retention secondary to a severe decrease in the glomerular filtration rate. B) Decreased serum phosphate level secondary to kidney failure. C) Metabolic alkalosis secondary to retention of hydrogen ions. D) Increased serum calcium level secondary to kidney failure.

*A* Water and sodium retention secondary to a severe decrease in the glomerular filtration rate. Rationale: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? A) Activity intolerance related to fatigue and pain. B) Self-care deficit related to increasing joint pain. C) Ineffective coping related to chronic pain. D) Disturbed body image related to fatigue and joint pain.

*A* Activity intolerance related to fatigue and pain. Rationale: Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? A) Depression B) Neuropathy C) Hypoglycemia D) Hyperthyroidism

*A* Depression Rationale: Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite

Which outcome indicates that treatment of a client with diabetes insipidus has been effective? A) Fluid intake is less than 2,500 ml/day. B) Urine output measures more than 200 ml/hour. C) Blood pressure is 90/50 mm Hg. D) The heart rate is 126 beats/minute.

*A* Fluid intake is less than 2,500 ml/day. Rationale: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn't been effective

A nurse is teaching a client who has hepatitis B about home care. Which of the following should the nurse include int he teaching? (Select all that apply) A) limit physical activity B) avoid alcohol C) take acetaminophen for comfort D) wear a mask when in public places E) eat small frequent meals

*A* *B* *E* limit physical activity, avoid alcohol, eat small frequent meals Rationale: Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process. Alcohol is metabolized in the liver and should be avoided by the client. Small frequent meals promote improved nutrition due to the presence of anorexia.

A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following should the nurse include in the information? (Select all that apply) A) Apply an occlusive dressing after application B) Apply three to four times per day C) Wear gloves after application to lesions on the hands D) Avoid applying in skin folds E) Use medication continuously over a period of several months

*A* *C* *D* Apply an occlusive dressing after application Wear gloved after application to lesions on the hands Avoid applying to skin folds Rationale: An occlusive dressing and gloves worn after the med can enhance the efficacy of the topical corticosteroid on the exposed lesions. Corticosteroid cream applied to the lesions in skin folds increases the risk of yeast infections

A nurse is planning care for a client who has burn injuries. Which of the following interventions should be included in the plan of care? (Select all that apply) A) Use standard precautions when performing wound care B) Encourage fresh vegetables in the diet C) Increase protein intake D) Instruct client to consume 3,000 calories per day E) Restrict fresh flowers in room

*A* *C* *E* Use standard precautions, increase protein, restrict fresh flowers Rationale: Standard precautions should be used to decrease the risk of infections. Increased protein intake promotes wound healing and prevents tissue breakdown. Flowers should not be in the client's room due to the bacteria they carry, which increase the risk for infection

A nurse is discharging a client diagnosed with a urinary tract infection. Which information should the nurse include in the discharge teaching? Select all that apply. A) Avoid coffee, tea, and alcohol B) Wipe from back to front C) Strain all urine D) Take all antibiotics as prescribed E) Limit fluid intake

*A* *D* Avoid coffee, tea and alcohol; take all antibiotics as prescribed Rationale: coffee, tea, and alcohol are urinary tract irritants. Wiping from back to front can spread bacteria to the urethra, causing a UTI. Straining all urine is not necessary, as the patient does not have a kidney stone. Finishing the abx as prescribed is important to make sure all UTI bacteria are gone, and the infection will not continue. Limiting fluid intake can lead to dehydration, and kidney damage.

Antiretroviral drugs are used to A) Cure acute HIV infection. B) Decrease viral RNA levels. C) Treat opportunistic diseases. D) Decrease pain and symptoms in terminal disease.

*B* Decrease viral RNA levels. Rationale: Antiretroviral drugs do not treat opportunistic infections, and do no treat HIV itself -- it is incurable. Antiviral drugs also do not decrease pain and symptoms of the disease, instead they lower the viral load.

A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following should the nurse include in the teaching? A) Apply coal tar before each meal B) Administer a psoralen medication before the treatment C) Use this treatment every evening D) Remove the scales gently following each treatment

*B* Administer a psoralen medication before the treatment Rationale: PUVA treatment involves the administration of a medication, such as psoralen, to enhance photosensitivity

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding? A) Presence of immunoglobin G antibodies (IgG) B) Presence of enzyme immunoassay (EIA) C) Aspartate aminotransferase (AST) 35 units/L D) Alanine aminotransferase (ALT) 15 IU/L

*B* Presence of enzyme immunoassay (EIA) Rationale: The presence of enzyme immunoassay is an expected laboratory in a patient that has a new diagnosis of hepatitis C.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 DM. Which of the following actions should the nurse implement? A) Check BG immediately after breakfast B) Administer insulin when breakfast arrives C) Hold breakfast for 1 hr after insulin administration D) Clarify prescription because inulin should not be administered at this time

*B* Administer insulin when breakfast arrives Rationale: Administer rapid acting insulin when breakfast arrives to avoid a hypoglycemic episode. Aspart insulin is rapid-acting, and should be administered 5 to 10 min before breakfast.

The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? A) Presence of HIV antibodies and draining fatigue B) CD4+ T cell count below 200 and Kaposi's Sarcoma C) Presence of oral hairy leukoplakia and flu like symptoms D) White blood cell count below 5000 and strep throat

*B* CD4+ T cell count below 200 and Kaposi's Sarcoma Rationale: Diagnostic criteria for AIDS include a CD4+ T cell count below 200/µL and/or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease but do not define the advancement of HIV infection to AIDS.

A nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A) Personal protective equipment B) Combination antiretroviral therapy C) Counseling to report blood exposures D) A negative evaluation by the manager

*B* Combination antiretroviral therapy Rationale: Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first

Rotating injection sites when administering insulin prevents which of the following complications? A) Insulin edema B) Insulin lipodystrophy C) Insulin resistance D) Systemic allergic reactions

*B* Insulin lipodystrophy Rationale: Insulin lipodystrophy produces fatty masses at the injection sites, causing unpredictable absorption of insulin injected into these sites.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? A) High-carbohydrate, high-protein B) Low-protein, low-sodium, low-potassium C) High-calcium, high-potassium, high-protein D) Low-protein, high-potassium

*B* Low-protein, low-sodium, low-potassium Rationale: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

A nurse is providing teaching to a client who has a prescription for methotrexate (Trexall) for severe psoriasis. Which of the following information should the nurse include? A) Drink a glass of wine daily B) Monitor for evidence of infection C) Monitor kidney function tests regularly D) Expect increased bruising

*B* Monitor for evidence of infection Rationale: The client should monitor for fever and sore throat, which are signs of infection. Methotrexate can cause blood dyscrasias such as leukopenia.

A nurse is caring for a client who a spinal cord injury who reports a severe headache and is sweating profusely. BP is 220/110 with a heart rate of 54/min. Which of the following actions should the nurse take first? A) Notify provider B) Sit the client upright in bed C) Check the urinary catheter for blockage D) Administer antihypertensive medications

*B* Sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure. The first action by the nurse is to elevate the head of the bed until the client is in an upright position. This will lower the blood pressure secondary to postural hypotension.

The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make? A) Testicular cancer is very difficult to diagnose B) Testicular cancer is a highly curable type of cancer. C) Testicular cancer is the number one cause of death in males. D) Testicular cancer is more common on older men.

*B* Testicular cancer is a highly curable type of cancer. Rationale: Testicular cancer is highly curable particularly when it is treated in its early stage. Self-examinations allow early detection and facilitate the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men ages 15-40 years old

The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. A) Thirst B) Palpitation C) Diaphoresis D) Slurred speech E) Hyperventilation

*B* *C* *D* Palpitation, Diaphoresis, Slurred Speech Rationale: Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

A nurse is educating a female client on the use of calcipotriene (Dovonex) topical medication for the treatment of psoriasis. Which of the following information should the nurse include? (Select all that apply) A) Recommended for facial lesions B) Expect a stinging sensation upon application C) Apply to the scalp D) Obtain a pregnancy test E) Limit application to skin folds

*B* *C* *D* *E* Expect a stinging sensation upon application, apply to the scalp, obtain a pregnancy test, limit application to skin folds Rationale: Calcipotriene causes a stinging and burning sensation when applied and should be applied to scalp lesions. It can cause birth defects, so female clients should obtain a pregnancy test before use. Applying to skin folds can cause a possible local reaction of itching, irritation, and erythema

A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Which of the following is an expected assessment finding? (Select all that apply) A) Anorexia B) Change in orientation C) Asterixis D) Ascites E) Fetor hepaticus

*B* *C* *E* Change in orientation, asterixis, fetor hepaticus Rationale: A change in orientation indicates worsening hepatic encephalopathy. Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. Fetor hepaticus, a fruity breath odor, is a clinical finding of worsening hepatic encephalopathy in the client who has advanced cirrhosis.

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply. A) Remind health care providers to draw blood from veins on the left side. B) Assess fingers on the left arm for warmth. C) Obtain blood pressure from the left arm. D) Wear wrist watch on the right arm. E) Avoid sleeping on the left arm.

*B* *D* *E* Assess fingers on the left arm for warmth, Wear wrist watch on the right arm, Avoid sleeping on the left arm. Rationale: Assess the fingers for warmth to ensure that blood is flowing to the extremities, do not draw blood, obtain a BP, sleep, or wear a watch on the side of the fistula as it can cause damage or a clot to form.

A nurse is preparing to administer fentanyl to a client who was admitted 24 hr ago with deep partial-thickness and full-thickness burns over 60% of his body. The nurse should plan to use which of the following routes to administer the medication? A) SQ B) IM C) IV D) Transdermal

*C* IV The intravenous route is used is used to administer pain meds because it provides rapid pain relief.

A client has experienced a left-hemispheric stroke, which of the following would be an expected finding? A) Impulse control difficulty B) Poor judgement C) Inability to recognize familiar objects D) Loss of depth perceptions

*C* Inability to recognize familiar objects Rationale: a client who experiences a left-hemispheric stroke will demonstrate the inability to recognize familiar objects. This is also known as agnosia

A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice is hoarse, and he has a brassy cough. These findings are indicative of which of the following? A) Pulmonary edema B) Bacterial pneumonia C) Inhalation injury D) Carbon monoxide poisoning

*C* Inhalation injury Rationale: Wheezing and hoarseness are indicative of inhalation injury and should be reported to the provider immediately.

.A 55 year old Asian man has a PSA level of 4.8 mg/mL. Based on the patient's PSA level, which of the following assessment questions does the nurse need to ask? A) "Will you remember to schedule your next PSA test in 1 year?" B) "How often do you include foods high in purine in your diet?" C) "When was the last time you experienced ejaculation?" D) "Do you wear boxers or briefs?"

*C* "When was the last time you experienced ejaculation?" Rationale: Values of PSA may increase after ejaculation. PSA levels are measured in ng/mL. In most laboratories, values less than 4.0 ng/mL are generally considered normal, and values greater than 4.0 ng/mL are considered elevated. Foods high in purines place individuals at risk for gout, but purines do not increase PSA levels. Because the patient's PSA level is elevated, further assessment is indicated. Type of underwear affects how close the testes are held to the body and may affect male fertility; type of underwear will not affect PSA levels

The nurse is instructing an unlicensed health care worker on the care of the client with HIV. Which statement by the health care worker indicates effective teaching of standard precautions? A) ''I need to know my HIV status, so I must get tested before caring for any clients." B) ''Putting on a gown and gloves will cover up the itchy sores on my elbows.'' C) ''Washing my hands is always necessary before entering the patient's room." D) ''I will wash my hands before going into the room, and then again only after touching something soiled."

*C* ''Washing my hands is always necessary before entering the patient's room." Rationale: Knowing HIV status is important for preventing transmission of HIV, but is not a standard precaution. Health care workers with open or weeping sores should not provide direct client care regardless of the use of gown and gloves. Washing hands before entering a patient's room, before touching a patient or any surroundings, and upon leaving the room.

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: A) Limited motion of joints. B) Deformed joints of the hands. C) Early morning stiffness. D) Rheumatoid nodules

*C* Early morning stiffness. Rationale: Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.

Screening for HIV infection generally involves: A) Laboratory analysis of blood to detect HIV antigen. B) Electrophoretic analysis for HIV antigen in plasma. C) Laboratory analysis of blood to detect HIV antibodies. D) Analysis of lymph tissues for the presence of HIV RNA.

*C* Laboratory analysis of blood to detect HIV antibodies. Rationale: The most useful screening tests for HIV detect HIV-specific antibodies. (Other methods are not necessarily wrong, but the most common ones screen for HIV antibodies)

A nurse is caring for a client who has BG 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse first perform? A) Recheck BG in 15 min B) Provide carbohydrate and protein food C) Provide 4 oz grape juice D) Report findings to provider

*C* Provide 4 oz grape juice Rationale: The client's acute need for a rapidly absorbed carbohydrate, such as grape juice, takes priority when treating the blood glucose of 52 mg/dL

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? A) Infusing I.V. fluids rapidly as ordered B) Encouraging increased oral intake C) Restricting fluids D) Administering glucose-containing I.V. fluids as ordered

*C* Restricting fluids Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse effect? A) Dysuria B) Leg cramps C) Tachycardia D) Blurred vision

*C* Tachycardia Rationale: Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine

A nurse is caring for a client who was admitted 24 hr ago with deep partial-thickness and full-thickness burns to 40% of his body. Which of the following are expected findings in this client? (Select all that apply) A) Hypertension B) Bradycardia C) Hyperkalemia D) Hyponatremia E) Decreased Hct

*C* *D* Hyperkalemia, Hyponatremia Rationale: Hyperkalemia occurs when a client is in shock as a result of leakage of fluid from the intracellular space. Hyponatremia occurs as a result of sodium retention in the interstitial space.

A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? A) "You are probably exercising too much. Decrease your exercise to every other day." B) "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." C) "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." D) "Take a warm tub bath or shower before exercising. This may help with your discomfort."

*D* "Take a warm tub bath or shower before exercising. This may help with your discomfort." Rationale: Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? A) Proper body alignment. B) Elevating the part. C) Prone lying positions. D) Positions of flexion.

*D* Positions of flexion. Rationale: Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism? A) Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess B) Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing C) Body image disturbance related to weight gain and edema D) Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

*D* Imbalanced nutrition: Less than body requirements related to thyroid hormone excess Rationale: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options B and C may be appropriate for a client with hypothyroidism, which slows the metabolic rate

Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? A) Anemia. B) Osteoporosis. C) Weight loss. D) Local joint pain.

*D* Local joint pain. Rationale: Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid arthritis, which has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? A) Absence of protein B) Absence of glucose C) Specific gravity of 1.03 D) Urine pH of 3.0

*D* Urine pH of 3.0 Rationale: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.