Pathophysiology / Med-Surg NCLEX
A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101° F (38.3° C) and a reddened, warm area in the mid-calf region over the shaft of the tibia. Based on this information, what should the nurse do? Select one: a. Develop a plan for pain management. b. Obtain a prescription for fluid replacement. c. Instruct the client to stay immobile. d. Prepare the client for possible left lower leg amputation.
A
A 32-year-old client with ovarian cancer is receiving hydroxyurea, an antineoplastic drug. Which finding indicates that the medication is having a therapeutic effect? Select one: a. Client's Ca 125 tumor marker level is decreasing. b. White blood cell count is 2300 cells/mm3. c. Client's menses has stopped. d. Client is free from nausea and vomiting.
A
A client is to be discharged from the hospital 4 days after undergoing a total hip arthroplasty. Which of the following statements by the client indicates a need for additional discharge instructions? Select one: a. "I can sleep in any position that is comfortable for me." b. "I will use a toilet elevator on the toilet seat." c. "I should not cross my legs while sitting." d. "I will have my wife put on my shoes and socks."
A
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia? Select one: a. Atrophy of the gastric mucosa b. Dulling of nerve impulses c. Decrease in intestinal flora d. Increase in bile secretion
A
A nurse is caring for a client who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the client when providing client education about effective pain management? Select one: a. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." d. "You need to take oral pain medications when you experience severe pain."
A
A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem? Select one: a. Post-traumatic stress disorder b. Alarm reaction c. Developmental crisis d. General adaptation syndrome
A
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Select one: a. Administer epinephrine, as prescribed, and prepare to intubate the client, if necessary. b. Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as prescribe. c. Prepare to administer a corticosteroid IV. d. Administer the antidote for penicillin, as prescribe, and continue to monitor the client's vital signs.
A
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? Select one: a. The client will be immobile during and shortly after surgery. b. The client usually walks 3 miles (4.8 kilometers) a day. c. The client is 5 feet 9 inches (172.5 cm) tall and weighs 128 lb (58 kg). d. The client has been pregnant four times.
A
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following? Select one: a. Cold intolerance. b. Bradycardia. c. Nausea. d. Decreased salivation.
A
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should: Select one: a. Monitor serum albumin. b. Monitor the white blood cell count. c. Have the client walk at least twice a day. d. Insert an indwelling urinary catheter.
A
When giving home care instructions to a client who has multiple forearm fractures and a long arm cast on the right arm, which information should the nurse include? Select one: a. Call the health care provider if you have increased swelling or numbness. b. Keep the right shoulder elevated on a pillow or cushion. c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. d. Keep the hand immobile to prevent soft tissue swelling.
A
When teaching a client with an extracapsular hip fracture scheduled for surgical internal fixation with the insertion of a pin, the nurse bases the teaching on the understanding that this surgical repair is the treatment of choice. Which of the following explains the reason? Select one: a. The client is able to be mobilized sooner. b. Hemorrhage at the fracture site is prevented. c. The risk of infection at the site is lessened. d. Neurovascular impairment risk is decreased.
A
Which nursing diagnosis takes highest priority for a client with a compound fracture? Select one: a. Risk for infection related to effects of trauma b. Imbalanced nutrition: Less than body requirements related to immobility c. Activity intolerance related to weight-bearing limitations d. Impaired physical mobility related to trauma
A
A 6-year-old boy is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report? Select one: a. Antipyretic b. Antibiotic c. Analgesic d. Anti-inflammatory
B
A client is diagnosed with esophageal cancer and presents with difficulty swallowing. Which intervention should receive the highest priority? Select one: a. Helping the client cope with impending body image changes b. Establishing aspiration precautions c. Providing preoperative teaching for tracheostomy care d. Ensuring adequate nutrition given the client's recent weight loss of 20 lbs (9.07 kg)
B
A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used? Select one: a. Hypoventilation b. Pruritus c. Nausea d. Psoriasis
B
A client with end-stage dementia is admitted to the orthopedic unit after undergoing open surgery for internal fixation of a right hip fracture. How should the nurse manage the client's postoperative pain? Select one: a. Administer oral opioids as needed. b. Administer analgesics around the clock. c. Administer pain medication through a transdermal patch. d. Provide client-controlled analgesia.
B
A client with newly diagnosed HTN has a blood pressure of 158/98 mm Hg after 12 months of exercise and diet modifications. How does the nurse advise the client? Select one: a. Because lifestyle modifications were not effective, they do not need to be continued and drugs will be used. b. Medication may be required because the BP is still not within the normal range. c. Continued monitoring of the BP every 3 to 6 months is all that will be necessary for treatment. d. The client will have to make more vigorous changes in lifestyle if the client wants to stay off medication for HTN.
B
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? Select one: a. "Generally caused by decreased blood volume" b. "A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" c. "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" d. "It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation."
B
A nurse is caring for a client with a urinary tract infection. The client is anemic and has a hemoglobin count of 80 mg/L. Taking into consideration that the client is from a Mediterranean country, what should the nurse's most appropriate action be? Select one: a. Ensure that the client takes care of personal hygiene. b. Ensure that the client takes haematinics for anemia. c. Ensure that the client takes adequate fluids. d. Ensure that drugs exacerbating anemia are not given.
B
A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? Select one: a. Heparin will dissolve the clot that is blocking blood flow to the heart. b. Heparin will prevent the development of new clots in the coronary arteries. c. Platelet aggregation is enhanced by IV heparin infusion. d. Coronary artery plaque size and adherence are decreased with heparin.
B
After administering oxycodone for complaints of pain, which of the following interventions would be of highest priority for the nurse to complete before leaving the client's room? Select one: a. Offer to turn on the television to provide distraction. b. Ensure that the upper two siderails are raised. c. Leave the overbed light on at low setting. d. Ensure that documentation of intake and output is accurate.
B
An elderly client has been bedridden since a stroke that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client? Select one: a. Urinary incontinence. b. Right-sided paralysis. c. Nutritional status. d. Episodes of confusion.
B
How can a client with chronic HF best decrease the chances of having an acute decompensation? Select one: a. Taking extra furosemide when shortness of breath occurs b. Monitoring weight daily and reporting changes outside of recommended parameters c. Resting and not making any exertions except under medical supervision d. Documenting fluid intake and urinary output each day
B
In reviewing medication instructions with a client being discharged on antihypertensive medications, which of the following statements would be most appropriate for the nurse to make when discussing atenolol (an alpha adrenergic blocker)? Select one: a. "A fast heart rate is an adverse effect to watch for while taking atenolol." b. "Make position changes slowly, especially when going from lying down to a standing position." c. "Because this drug may affect the lungs in large doses, it may also help your breathing." d. "Stop the drug and notify your doctor if you experience any nausea or vomiting."
B
Target-organ damage that can occur from hypertension includes which of the following? Select one: a. Headache and dizziness b. Renal dysfunction and left ventricular hypertrophy c. Hypercholesterolemia and renal dysfunction d. Retinopathy and diabetes
B
The nurse includes which of the following ideas in teaching a client with hypertension about controlling the condition? Select one: a. All clients with elevated BP require medication. b. Lifestyle modifications are indicated for all people with elevated BP. c. Obese people must achieve a normal weight in order to lower BP. d. It is not necessary to limit salt in the diet if taking a diuretic.
B
The nurse is caring for two clients; both are having a hysterectomy. The first client is having the hysterectomy after a complicated birth. The second client has uterine cancer. What will most likely influence the experience of pain for these two clients? Select one: a. Postoperative support personnel b. Meaning of pain c. Neurological factors d. Competency of the surgeon
B
The nurse would recognize that indications for the use of dopamine (an alpha adrenergic agonist) in the care of a client with heart failure include: Select one: a. acute anxiety. b. hypotension and tachycardia. c. paroxysmal nocturnal dyspnea (PND). d. peripheral edema and weight gain.
B
To reduce the risk of adverse effects, the nurse should do which of the following when caring for a client receiving morphine sulphate via client-controlled analgesia (PCA)? Select one: a. Instruct the client not to push the button too frequently. b. Teach the caregiver not to push the button for the client. c. Ask the client to do deep breathing exercises every hour. d. Administer medications to prevent the occurrence of diarrhea.
B
What is the indication for use of antiretroviral drugs in the setting of HIV? Select one: a. Supplement radiation and surgery b. Decrease viral RNA levels c. Cure acute HIV infection d. Treat opportunistic diseases
B
When providing dietary instruction to a client with hypertension, the nurse would advise the client to restrict intake of which of the following meats? Select one: a. Baked chicken breast b. Roasted duck c. Broiled fish d. Roasted turkey breast
B
When receiving the 15th dose of an antibiotic I.V., a child begins scratching at the I.V. site on the forearm and develops small, circumscribed, elevated areas on the same arm. What should the nurse do first? Select one: a. Remove the I.V. line and restart it in another area. b. Stop the infusion of the antibiotic but continue the I.V. fluids. c. Assess the I.V. site for localized edema or redness. d. Apply a cold compress to the area and continue to deliver the antibiotic.
B
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? Select one: a. altered level of consciousness b. anaphylactic reaction c. pain d. fluid balance
B
Which statement made by a nursing educator best explains why it is important for nurses to determine a client's medical history and recent drug use? Select one: a. "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." b. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." c. "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." d. "Getting this information gives the nurse an opportunity to provide client teaching about drug abstinence."
B
A 72-year-old client is in a long-term care facility after having had a stroke. The client is noncommunicative, enteral feedings are not being absorbed, and respirations are becoming laboured. The stage of the general adaptation syndrome that this client is experiencing is the: Select one: a. Resistance stage. b. Reflex pain stage. c. Exhaustion stage. d. Alarm reaction stage
C
A client with Graves' disease is prepared for surgery with drug therapy consisting of 4 weeks of propylthiouracil (PTU) and 10 days of iodine prior to surgery. When teaching the client about the drugs, the nurse explains that the drugs are given preoperatively to do which of the following? Select one: a. Assist in locating the thyroid and parathyroid glands during surgery b. Decrease the risk of hypometabolism during and after the surgery c. Normalize metabolism and decrease the size and vascularity of the gland d. Eliminate the risk for postoperative tetany
C
A client with a diagnosis of heart failure (HF) has been started on a nitroglycerin patch (a nitrate) by his primary care provider. This client should be advised to avoid: Select one: a. high-potassium foods. b. nonsteroidal anti-inflammatory drugs (NSAIDs). c. drugs to treat erectile dysfunction. d. over-the-counter H2-receptor blockers.
C
A client with a fracture develops compartment syndrome. Which sign should alert the nurse to impending organ failure? Select one: a. generalized edema b. Crackles c. dark, scanty urine d. jaundice
C
A male client with chronic renal failure (CRF) has a hemoglobin of 102 g/l and hematocrit of 40%. Which of the following would be a primary assessment? Select one: a. Presence of dyspnea and cyanosis b. Presence of edema and fluid volume overload c. Presence of fatigue and weakness d. Presence of thrush and circumoral pallor
C
A nurse is caring for a client with a urinary tract infection. The client is anemic and has a hemoglobin count of 80 mg/L. Taking into consideration that the client is from a Mediterranean country, what should the nurse's most appropriate action be? Select one: a. Ensure that the client takes haematinics for anemia. b. Ensure that the client takes adequate fluids. c. Ensure that drugs exacerbating anemia are not given. d. Ensure that the client takes care of personal hygiene
C
On the first postoperative day, a client with a below-the-knee amputation complains of pain in the amputated limb. What is an appropriate nursing action? Select one: a. Ask the client to ignore the pain because it is not real. b. Tell the client that this phantom pain will diminish over time with increasing awareness of the absence of the limb. c. Administer prescribed opioids to relieve the pain. d. Loosen the compression bandage to prevent pressure on the surgical incision.
C
The health care provider initially prescribes bedrest for a client with a fractured pelvis. During assessment of the client, which of the following findings would alert the nurse to a complication of the fracture? Select one: a. Ecchymosis of the lower abdomen b. Unusual pelvic movement c. Absence of bowel sounds d. Lower abdominal tenderness
C
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with what type of immunity? Select one: a. Passive immunity to all childhood illnesses for several months b. Active immunity for several years to diseases to which the mother has immunity c. Passive immunity to diseases to which the mother has immunity d. Indefinite active immunity to childhood illnesses
C
The nurse teaches a client with hypertension (HTN) that uncontrolled hypertension may damage organs in the body primarily by which of the following mechanisms? Select one: a. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions. b. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. c. Hypertension promotes atherosclerosis and damage to the walls of the arteries. d. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue.
C
A 72-year-old client is in a long-term care facility after having had a stroke. The client is noncommunicative, enteral feedings are not being absorbed, and respirations are becoming laboured. The stage of the general adaptation syndrome that this client is experiencing is the: Select one: a. Reflex pain stage. b. Alarm reaction stage c. Resistance stage. d. Exhaustion stage.
D
A 73-year-old woman tells the nurse that she is "slowing down" and does not try to push herself to do much these days because of her age. She spends most of the day and evening watching television and has hired someone to do most of her home maintenance chores. Recognizing that the woman is at risk for musculoskeletal problems, what is the best response to her comment? Select one: a. "Many musculoskeletal changes occur with age that limit physical activities. This is normal and to be expected." b. "To improve your condition, you should join an exercise program, perhaps one at your local senior centre." c. "Many older people benefit from occasional exercise, which helps prevent muscle wasting and fatigue common in old age." d. "Regular exercise will increase your strength and coordination and help increase your sense of well-being."
D
A client complains of pain in a cutaneous site that is different from where it originates. How does the nurse document this pain? Select one: a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain
D
A client is scheduled for dual-energy X-ray absorptiometry (DEXA) testing. What would the nurse recognize that the client is most likely being evaluated for? Select one: a. Intravertebral disk disease b. Bone tumours c. Arthritis d. Osteoporosis
D
A client with kyphosis is scheduled for dual-energy X-ray absorptiometry (DEXA) testing. Which will the nurse plan to do? Select one: Screen the client for shellfish allergies. b. Give an oral sedative. c. Start an intravenous line. d. Teach the client that DEXA is noninvasive.
D
A holistic nurse would be a nurse who: Select one: a. Knows about resources for fresh herbs. b. Provides spiritual literature to clients. c. Recommends a vegan diet for all clients. d. Recognizes the mind-body-spirit connection
D
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? Select one: a. Hypermagnesemia b. Hyperkalemia c. Hypernatremia d. Hypercalcemia
D
After falling at home, an 81-year-old man was admitted to the emergency department, where X-rays confirmed the presence of an extracapsular fracture of the femur. Upon initial assessment, what would the nurse expect to find? Select one: a. Bruising of the left hip and thigh b. Numbness in the left leg and hip c. Weak or nonpalpable left leg pulses d. Outward-pointing toes on the left leg
D
Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition? Select one: a. Anemia b. Jaundice c. Dehydration d. Compensation for hypoxia
D
The home care nurse visits a client with chronic heart failure. Which clinical manifestations, as assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? Select one: a. Oxygen saturation at 90% and respirations 26 breaths/min b. Temperature 38°C and pulse 102 beats/min c. Fatigue, orthopnea, and dependent edema d. Severe dyspnea and blood-streaked frothy sputum
D
The nurse assesses that a client who has had a partial gastrectomy has a decreased hemoglobin and hematocrit. The nurse explains to the client that the partial gastrectomy has most likely contributed to which of the following? Select one: a. A folate deficiency b. An iron deficiency c. A vitamin C deficiency d. A vitamin B12 deficiency
D
The nurse is caring for a client who has a pressure ulcer. The client has a 20-year history of smoking. What effect does smoking have on wound healing? Select one: a. It decreases the blood supply in fatty tissue. b. It decreases the supply of nutrients to the injured area. c. It slows collagen synthesis by fibroblasts. d. It impedes blood flow to healing areas.
D
The nurse is caring for a client who is receiving morphine sulphate via PCA. Which of the following client assessment data demonstrate the most therapeutic effect of this medication? Select one: a. Pain rating 3/10, awake and alert, respirations 20 b. Pain rating 1/10, drowsy but arousable, respirations 16 c. Pain rating 2/10, drowsy but arousable, respirations 18 d. Pain rating 2/10, awake and alert, respirations 18
D
The nurse is caring for a client with hypertension who is scheduled to receive a dose of atenolol (an alpha adrenergic blocker). The nurse should withhold the dose and consult the prescribing health care provider for which of the following vital signs taken just before administration? Select one: a. Oxygen saturation 93% b. Respirations 24 c. Blood pressure 118/74 d. Pulse 48
D
What are the manifestations of systolic heart failure (HF) that the nurse should recognize? Select one: a. Decreased Afterload and decreased left ventricular end-diastolic pressure (LVEDP) b. increased Pulmonary hypertension associated with normal EF c. decreased PAOP and increased left ventricular EF d. decreased Ejection fraction (EF) and increased pulmonary artery occlusive pressure (PAOP)
D
What is a major consideration in the management of the older adult with HTN? Select one: a. Ensure that the client receives larger initial doses of antihypertensive drugs because of impaired absorption. b. Prevent pseudohypertension from converting to true HTN. c. Recognize that the older adult is less likely to adhere to the drug therapy than a younger adult. d. Use careful technique in assessing the BP of the client because of the possible presence of an auscultatory gap.
D
When performing preoperative teaching for a client who is scheduled for an open reduction and internal fixation of a left intertrochanteric hip fracture, what should the nurse inform the client regarding the expected outcome of this surgery? Select one: a. The ability to ambulate several days after surgery with full weight bearing on the affected limb b. Restriction of activity to bedrest and sitting in a chair c. Confinement in bed with skeletal traction applied to the distal part of her femur d. Early ambulation with the use of an assistive device, such as a walker or crutches
D
Which nursing diagnosis takes highest priority for a client with a compound fracture? Select one: a. Activity intolerance related to weight-bearing limitations b. Imbalanced nutrition: Less than body requirements related to immobility c. Impaired physical mobility related to trauma d. Risk for infection related to effects of trauma
D
Which sign indicates that a client with a fracture of the right femur may be developing a fat embolus? Select one: a. muscle spasms in the right thigh b. numbness in the right leg c. migraine-like headaches d. acute respiratory distress syndrome
D
Which statement made by a nursing educator best explains why it is important for nurses to determine a client's medical history and recent drug use? Select one: a. "Getting this information gives the nurse an opportunity to provide client teaching about drug abstinence." b. "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." c. "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." d. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief."
D
When teaching a client with chronic SIADH about long-term management of the disorder, the nurse determines that additional instruction is needed when the client gives which of the following responses?Select one: a. "I should weigh myself daily and report a sudden loss or gain." b. "I will eat foods high in potassium because the diuretics cause potassium loss." c. "I need to maintain a sodium-restricted diet at home." d. "I need to limit my fluid intake to no more than 950 mL of liquids a day."
c
Which of the following factors related to cerebral blood flow most often determines the extent of cerebral damage from a stroke? Select one: a. Level of carbon dioxide in the blood b. Oxygen content of the blood c. Degree of collateral circulation d. Amount of cardiac output
C
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? Select one: a. Pupil size and pupillary response. b. Cholesterol level. c. Echocardiogram. d. Bowel sounds.
A
A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis and bone demineralization, which objective is most appropriate? Select one: a. Promoting range-of-motion (ROM) exercises b. Promoting weight-bearing exercises c. Maintaining vitamin levels d. Maintaining protein levels B
B
What is the most common repsonse of the stroke client to the change in body image? Select one: a. Dissociation b. Depression c. Intellectualization d. Denial
B
During a health history, a 43-year-old client complains of difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? Select one: a. Hyperopia b. Myopia c. Astigmatism d. Presbyopia
D
A 20-year-old university student who has type 1 diabetes normally walks each evening as part of her exercise regimen. She now plans to enroll in a swimming class to meet her physical education requirement. What should the nurse teach the client that adjustments to her treatment plan should include? Select one: a. Monitoring her glucose level before, during, and after swimming to determine the need for alterations in food or insulin b. Adding 10 units of regular insulin to her usual morning dose on the days she plans to swim c. Delaying the normal meal before the swimming class until the session is over d. Timing her morning insulin injection so that the peak action will occur during her swimming class
A
A client admitted with metastatic lung cancer is prescribe to receive morphine sulphate for pain. The nurse should assess for which of the following common adverse reactions to this medication? Select one: a. Constipation b. Agitation c. Diarrhea d. Urinary incontinence
A
A client develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated? Select one: a. Assist the client to a sitting position at the bedside. b. Restrict oral fluid intake to 500 mL/day. c. Perform a bladder scan to assess for urinary retention. d. Instruct the client to use pursed-lip breathing.
A
A client is receiving 3% NaCl solution for correction of hyponatremia. What is important for the nurse to monitor during administration of the solution? Select one: a. Lung sounds b. Peripheral pulses c. Hourly urinary output d. Peripheral edema
A
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching and there is a rise in the client's temperature. The nurse stops the transfusion and notifies the health care provider. The nurse suspects which type of hypersensitivity reaction with a blood transfusion? Select one: a. Type II (cytolytic, cytotoxic) hypersensitivity reaction b. Type IV (cell-mediated, delayed) hypersensitivity reaction c. Type III (immune complex) hypersensitivity reaction d. Type I (immediate, anaphylactic) hypersensitivity reaction
A
When planning care for a client with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, which of the following elements should the nurse focus on? Select one: a. Encourage compliance with drug therapy for the glaucoma to prevent loss of vision. b. Give anticipatory guidance about the eventual loss of central vision that will occur. c. Manage the pain experienced by clients with glaucoma that persists until the optic nerve atrophies. d. Recognize that eye damage caused by glaucoma can be reversed in the early stages.
A
When providing postoperative care for a client who has had bilateral adrenalectomy, which assessment information obtained by the nurse is most important to communicate to the health care provider? Select one: a. The client's blood pressure is 95/50 mm Hg. b. The client has level 6 incisional pain on a 10-point scale. c. The blood glucose is 8 mmol/L. d. The client's respirations are shallow.
A
Which of the following is the priority for a client with a fractured femur who is in traction? Select one: a. Prevent effects of immobility while in traction. b. Choose appropriate diversional activities during the prolonged recover. c. Adapt to inactivity from the impaired mobility. d. Develop skills to cope with prolonged immobility.
A
While assessing a client who has just arrived in the postanaesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains the following data. Which information is most important to communicate to the surgeon? Select one: a. Rapidly increasing swelling of the neck b. Cardiac monitor showing a heart rate of 112 mm Hg c. Complaining of level 7 incisional pain on a 10-point scale d. A weak, hoarse voice
A
While caring for a client with an albumin deficiency, which of the following findings evaluated by the nurse indicates that the client's condition is improving? Select one: a. Decreased edema b. Improved skin turgor c. Decreased blood pressure d. Decreased hematocrit
A
A client with multiple commonly acquired nevi expresses concern about their presence and the possibility of malignant changes. What should the nurse advise? Select one: a. That malignant changes are characterized by scaling, ulceration, and an opaque appearance of the moles b. To consult the health care provider if the moles enlarge and develop irregular colouration or borders c. That only moles occurring on the back and chest are likely to become malignant d. To request removal of all nevi larger than 4 mm to prevent malignant change
B
A 30-year-old client has been diagnosed with hypothyroidism. What should the nurse expect to assess in this client's integumentary system? Select one: a. General hyperpigmentation and loss of body hair b. Cold, dry, pale skin, dry, coarse hair, and brittle, slow growing nails c. Warm, flushed skin, alopecia, and thin nails d. Pale skin, pale mucous membranes, hair loss, and nail dystrophy
B
A client at risk for lung cancer asks why he is scheduled for a computed tomography (CT) scan as part of the initial exam. The nurse's best response is which of the following? "A CT scan: Select one: a. "Can distinguish a malignant from a nonmalignant adenopathy." b. "Is useful for distinguishing small differences in tissue density and detecting nodal involvement." c. "Is far superior to magnetic resonance imaging for evaluating lymph node metastasis." d. "Is noninvasive and readily available."
B
A client being treated for non-healing diabetic foot ulcers tells the nurse angrily, "I am so frustrated with my doctors. The wound care doctor tells me this won't heal and I need to have my toes amputated. Then another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, the nurse should: Select one: a. Assure the client that the health care providers know what they are doing and to do what they say. b. Set up a care conference with the client, the family, and all health care providers involved. c. Review the health care provider's progress notes with the client. d. Remind the client of personal responsibilities for healthy habits regarding diabetes and to accept the consequences.
B
A client has a traumatic skin wound on his left thigh as a result of an accident at a construction site. You question the client regarding his immunization status. Your initial concern is determining his potential susceptibility to which infection? Select one: a. hepatitis b. tetanus c. staphylococcus d. streptococcus
B
A client has an adenoma of the adrenal zona glomerulosa causing hyperaldosteronism and is scheduled for surgery to remove the affected gland. During care prior to surgery, the nurse should do which of the following? Select one: a. Monitor blood glucose every 4 hours. b. Monitor the blood pressure every 4 hours. c. Elevate the client's extremities to relieve edema. d. Provide a potassium-restricted diet.
B
A client has been admitted with type 2 diabetes mellitus and asks to have the local medicine man come and help decide what traditional aboriginal medicines could help. What are the appropriate nursing interventions based on this client's request? Select one: a. Recommend that the client wait until the diabetes is under control and he/she is discharged home before using traditional medicines. b. Suggest that the client inform and discuss with the multidisciplinary team how traditional therapies could be integrated into the plan of care. c. Tell the client that traditional healing methods are not likely to work for control of diabetes. d. Let the client know there is a choice and a decision needs to be made as to whether traditional or medical means will be used to control the diabetes.
B
The nurse reviews a plan of care for a client who has sustained a deep laceration to an extremity. Which goal listed on the plan is inappropriate and should be questioned by the nurse? Select one: a. The client will be free of signs and symptoms of infection. b. The client will stop taking the antibiotics after 2 days if he detects no signs of infection. c. The client will report any change in sensation of the extremity distal to the laceration. d. The client will demonstrate how to change the sterile dressing on the laceration.
B
The nurse reviews a plan of care for a client who has sustained a deep laceration to an extremity. Which goal listed on the plan is inappropriate and should be questioned by the nurse? Select one: a. The client will report any change in sensation of the extremity distal to the laceration. b. The client will stop taking the antibiotics after 2 days if he detects no signs of infection. c. The client will demonstrate how to change the sterile dressing on the laceration. d. The client will be free of signs and symptoms of infection.
B
The nurse should recognize which client as likely to have the poorest prognosis? Select one: a. A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma b. A 59-year-old man who is being treated for stage IV malignant melanoma c. A 70-year-old woman who has been diagnosed with late squamous cell carcinoma (SCC) d. A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma
B
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? Select one: a. Echocardiogram. b. Pupil size and pupillary response. c. Cholesterol level. d. Bowel sounds.
B
Which of the following may be found on assessment of a 79-year-old client? Select one: a. A narrowed pulse pressure b. Difficulty in isolating the apical pulse c. Diminished carotid artery pulses d. An increased heart rate in response to stress
B
While assessing a client who has just arrived in the postanaesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains the following data. Which information is most important to communicate to the surgeon? Select one: a. A weak, hoarse voice b. Rapidly increasing swelling of the neck c. Complaining of level 7 incisional pain on a 10-point scale d. Cardiac monitor showing a heart rate of 112 mm Hg
B
A client is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. What symptoms should the nurse teach the client to report? Select one: a. Confusion and personality changes b. Abdominal cramping and diarrhea c. Anxiety and muscle twitching d. Fatigue and muscle weakness
D
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? Select one: a. "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." b. "The client is unaware of his left side. You need to encourage him to interact from this side." c. "The client is unaware of his left side. You should approach him on the right side." d. "This condition is temporary."
C
A client with Cushing's syndrome is admitted to the hospital in preparation for surgery to remove an adrenal tumour. During the admission assessment, the client tells the nurse that she looks so awful she does not want anyone to be around her. What is the best response to the client? Select one: a. "Let me show you how to dress so that the changes are not so noticeable." b. "You really should not worry about how you look in the hospital. We see many worse things." c. "Most of the physical and mental changes caused by the disease will gradually improve after surgery." d. "I do not think you look bad. Your appearance is just altered by your disease."
C
A client with a stroke is scheduled for angiography. Which of the following can this test detect in stroke clients? Select one: a. Site and size of the infarction b. Presence of blood in the cerebrospinal fluid c. Patency of the cerebral blood vessels d. Presence of increased intracranial pressure
C
A client with an antidiuretic hormone (ADH)-secreting small cell cancer of the lung is treated to control the symptoms of syndrome of inappropriate ADH (SIADH). The nurse determines that treatment is effective on finding which of the following data? Select one: a. The client's weight has increased. b. The client's edema is reduced. c. The client's urinary output is increased. d. The urine specific gravity is increased.
C
Physiological symptoms of a stress response include all of the following except: Select one: a. Elevated blood pressure. b. Constricted pupils. c. Tachypnea. d. Tachycardia.
C
The nurse is assessing an 86-year-old female who has just been transferred to the long-term care facility. Which of the following assessment questions will best allow the nurse to assess the woman for the presence of presbycusis? Select one: a. Do you ever experience any ringing in your ears? b. Do you ever have pain in your ears when you're chewing or swallowing? c. Have you noticed any change in your hearing in recent months and years? d. Have you ever fallen down because you became dizzy?
C
The priority nursing diagnosis for a client with Ménière's disease who is experiencing an acute attack is: Select one: a. self-care deficit (bathing and dressing) related to vertigo. b. imbalanced nutrition: less than body requirements related to nausea. c. risk for falls related to dizziness. d. impaired verbal communication related to tinnitus.
C
What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture? Select one: a. Supporting the leg to maintain adduction, ensuring adequate pain control, and maintaining bed rest b. Assessing for skin integrity, enhancing nutritional status, and encouraging position changes while maintaining bed rest c. Assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation d. Reorienting frequently to prevent confusion and disorientation, restricting analgesics, and encouraging pursed-lip breathing
C
Which client is most at risk for a stroke? Select one: a. An 82-year-old female who takes warfarin (Coumadin) for atrial fibrillation. b. A 28-year-old male who uses marijuana after chemotherapy to control nausea. c. A 72-year-old male who has hypertension, diabetes mellitus, and smokes heavily. d. A 42-year-old female who takes oral contraceptives and has migraine headaches.
C
Which of the following factors related to cerebral blood flow most often determines the extent of cerebral damage from a stroke? Select one: a. Amount of cardiac output b. Oxygen content of the blood c. Degree of collateral circulation d. Level of carbon dioxide in the blood
C
Which of the following is the first nursing action indicated when a client returns to the surgical nursing unit after a thyroidectomy? Select one: a. Check the back of the neck for hemorrhage. b. Determine whether the client can speak normally. c. Assess respiratory rate and effort. d. Ask the client whether he or she experiences any tingling in the toes or fingers.
C
A client recovering from diabetic ketoacidosis asks the nurse how acidosis occurs. What is the best response? Select one: a. Insufficient insulin leads to cellular starvation, and as cells rupture, they release organic acids into the blood. b. Excess glucose in the blood is metabolized by the liver into acetone, which is acidic in nature. c. When an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by products. d. An insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.
D
A client with a venous leg ulcer asks the nurse what the surgeon meant by "the wound will be allowed to heal by secondary intention." How should the nurse explain this to the client? Select one: a. The healing will contract the area to close the wound. b. The wound will be stapled together until it heals. c. The wound will be sutured after the current infection is controlled. d. The wound will be left open and heal from the edges inward.
D
A client being treated for non-healing diabetic foot ulcers tells the nurse angrily, "I am so frustrated with my doctors. The wound care doctor tells me this won't heal and I need to have my toes amputated. Then another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, the nurse should: Select one: a. Remind the client of personal responsibilities for healthy habits regarding diabetes and to accept the consequences. b. Review the health care provider's progress notes with the client. c. Assure the client that the health care providers know what they are doing and to do what they say. d. Set up a care conference with the client, the family, and all health care providers involved.
D
A client has a traumatic skin wound on his left thigh as a result of an accident at a construction site. Your time in the emergency clinic with the client has been brief, but you are able to set priorities for his care. Which of the following is pertinent and most important for Dave's care at this time? Select one: a. ineffective peripheral tissue perfusion related to left thigh inflammation b. impaired physical mobility related to injured left thigh c. risk for infection related to loss of protective skin barrier at injured left thigh d. fear related to potentially-serious injury to left thigh
D
A client is hospitalized with acute adrenal insufficiency causing hypoaldosteronism. Which of the following findings assists the nurse to determine that the client is responding favourably to treatment? Select one: a. Decreasing blood glucose b. Increasing urinary output c. Decreasing serum sodium d. Decreasing serum potassium
D
A health care provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Select one: a. Dexamethasone (corticosteroid) b. Heparin sodium (anticoagulant) c. Phenytoin (antiseizure) d. Methyldopa (alpha-adrenergic agonist
B
A client has an adenoma of the adrenal zona glomerulosa causing hyperaldosteronism and is scheduled for surgery to remove the affected gland. During care prior to surgery, the nurse should do which of the following? Select one: a. Monitor the blood pressure every 4 hours. b. Elevate the client's extremities to relieve edema. c. Monitor blood glucose every 4 hours. d. Provide a potassium-restricted diet.
A
A client has a traumatic skin wound on his left thigh as a result of an accident at a construction site. In caring for this client, your primary nursing goal is to: Select one: a. prevent infection of the wound b. cleanse and dress the client's wound utilizing principles of asepsis c. alleviate the client's fears about his wound d. prevent the transmission of microbes from the client's wound to other persons
A
The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee bites. The nurse identifies a need for additional teaching when the client makes which of the following statements? Select one: a. "I will need to take doses of corticosteroids to prevent reactions to further stings." b. "I should wear a MedicAlert bracelet indicating my allergy to insect stings." c. "I will learn to administer epinephrine so that I will be prepared if I am stung again." d. "I need to think about a change in my occupation."
A
The nurse is assessing a client who has a traumatic leg injury. What intervention is the most important in the initial assessment? Select one: a. Determine the extremity's color and temperature in the area of the injury b. Check for full or partial loss of feeling and sensation c. Assess the client's pain level d. Realign the extremity in the appropriate position
A
The nurse is providing discharge teaching to a client after a scleral buckling procedure for retinal detachment. Which statement, if made by the client, indicates that the discharge teaching is effective? Select one: a. "I should avoid lifting heavy objects and straining." b. "The procedure will correct my vision immediately." c. "I can expect severe pain after this procedure." d. "I doubt my other eye will ever be affected."
A
A client who has right-sided paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? Select one: a. Assist the client to the bathroom every 2 hours. b. Arrange for six servings per day of cooked fruits and vegetables. c. Administer a bisacodyl suppository every day. d. Provide incontinence briefs to wear during the day.
B
A client with terminal lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that more teaching is required when the wife does which of the following? Select one: a. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal. b. Avoids long-acting opioids due to her concern about addiction. c. Uses music for distraction as well as heat or cold in combination with medications. d. Administers long-acting or sustained-release oral pain formula regularly around-the-clock.
B
After a stroke, a client is admitted to the facility. The client is conscious, has left-sided weakness, and an absent gag reflex. He's incontinent and has a tarry black stool. His blood pressure is 100/60 mm Hg, and his hemoglobin is 100 g/L. Which nursing intervention is a priority for this client? Select one: a. Checking stools for occult blood b. Elevating the head of the bed to 30 degrees c. Performing range-of-motion (ROM) exercises on the left side d. Keeping skin clean and dry
B
Cardiac monitoring is initiated for a client in diabetic ketoacidosis. The nurse recognizes that this measure is important to identify which of the following complications? Select one: a. Cardiovascular collapse resulting from the effects of excess glucose on cardiac muscle b. Electrocardiogram (ECG) changes and dysrhythmias related to potassium imbalances c. The presence of hypovolemic shock related to osmotic diuresis d. Fluid overload resulting from aggressive fluid replacement
B
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: Select one: a. Temperature. b. Blood pressure. c. Pulse. d. Respirations.
B
The family of a client with a cerebrovascular accident (CVA, or stroke) asks the nurse why the client is not able to speak. What is the best response by the nurse? Select one: a. "Damage has occurred in the frontal lobe, which has caused the inability to speak." b. "Your mother has lost the primary sensory pathways between the eye and visual cortex that are responsible for speech." c. "Your mother should regain speech over the next couple of days. Don't worry about the inability to speak." d. "Your mother's difficulty with speaking has been caused by paralysis of the muscles responsible for producing speech."
D
A client with type 1 diabetes is found unresponsive in the morning by his wife and is admitted to the emergency department. On admission, the client is unresponsive to stimuli and has fruity, sweet breath with Kussmaul's respirations. Laboratory results include arterial blood gases of pH 7.32, PCO2 34 mm Hg, and HCO3- 11 mmol/L and a plasma glucose of 28.8 mmol/L. Which of the following interventions does the nurse anticipate will be prescribed initially for the client? Select one: a. Low-dose insulin infusion in a normal saline solution b. IV administration of sodium bicarbonate to replace bicarbonate and reverse the acidosis c. Administration of an IV bolus of regular insulin d. IV fluid and electrolyte replacement therapy
D
A female client has left-sided hemiplegia following an ischemic stroke that she experienced two weeks earlier. How should the nurse best promote the health of the client's integumentary system? Select one: a. Establish a schedule for the massage of areas where skin breakdown emerges. b. Position the client on her weak side the majority of the time. c. Avoid the use of pillows in order to promote independence in positioning. d. Alternate the client's positioning between supine and side-lying.
D
A male client with chronic renal failure (CRF) has a hemoglobin of 102 g/l and hematocrit of 40%. Which of the following would be a primary assessment? Select one: a. Presence of dyspnea and cyanosis b. Presence of edema and fluid volume overload c. Presence of thrush and circumoral pallor d. Presence of fatigue and weakness
D
A nurse is caring for a client who has left homonymous hemianopsia following a recent stroke. Which nursing diagnosis should take the highest priority? Select one: a. Activity intolerance b. Impaired verbal communication c. Impaired physical mobility d. Risk for injury
D
A nurse is designing a plan of care for a client with a soft tissue injury and related inflammation as a result of a motor vehicle accident. Which nursing intervention should be included in the plan? Select one: a. Keep the injured extremity moving for proper blood circulation. b. Use hot fomentation to increase the circulation at the inflamed site during initial trauma care. c. Avoid compression bandages, as they may compromise circulation. d. Elevate the injured extremity above the level of the heart to reduce pain
D
The nurse is teaching about skin cancer prevention at a community centre. Which individual is most at risk for developing skin cancer? Select one: a. A 67-year-old man who is a retired salesman with psoriasis and type 2 diabetes mellitus b. A 76-year-old man who has a latex allergy and numerous acrochordons c. A 62-year-old woman who has chronic kidney disease with dry, pale skin and pruritus d. A 55-year-old woman with fair skin and red hair who has a family history of skin cancer
D
The nurse states on shift handoff that the client has an elevated uric acid level of 8.2 mg/dl (487.8 mmol/L). Which inflammatory process would the nurse assess for during client assessment? Select one: a. Lupus erythematosus b. Osteoporosis c. Rheumatoid arthritis d. Gout
D
The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? Select one: a. "Rinse your eyes immediately with water." b. "Keep your eyes open to allow tears to form." c. "Remove any visible metal fragments." d. "Apply a loose dressing over your eyes."
D
When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the health care provider will order? Select one: a. Irrigation b. Culture and sensitivity tests c. Incision and drainage d. Debridement to remove necrotic tissue
D
When studying the incidence of skin cancers in a population, a nurse finds that a greater number of skin cancer cases have been reported in white clients than in Canadians of African descent. What could be the most likely cause of such an occurrence? Select one: a. Whites usually have more exposure to the sun than African Canadians. b. Whites usually have less exposure to the sun than African Canadians. c. Whites have greater melanin content in their skin than African Canadians. d. Whites have less melanin content in their skin than African Canadians.
D
In addition to the manifestations noted in the initial health assessment, which of the following observations may be additional manifestations of Cushing's syndrome? Select One: a. Acne, fragile skin, petechiae and a small cut that has been slow to heal b. Hypotension and hypoglycemia c. Decreased axilla and pubic hair d. Tachycardia and bulging eyes
A
Spironolactone (potassium-sparing), an aldosterone antagonist, is prescribed for an elderly client as a diuretic. What dietary modifications should the nurse teach the client to prevent electrolyte imbalances? Select one: a. Decreasing foods high in potassium b. Restricting fluid intake to 1000 mL/day c. Increasing foods high in sodium d. Increasing intake of milk and milk products
A
Following bowel surgery, a client has been receiving normal saline intravenous (IV) fluids at 100 mL/hr; has a nasogastric tube attached to low, intermittent suction; and is nothing by mouth (NPO) status. Which of the following assessment findings would alert the nurse to a major fluid and electrolyte problem? Select one: a. A decreasing level of consciousness (LOC) b. Weight gain c. Flushed, moist skin d. A serum sodium level of 138 mmol/L
A
A client in acid-base imbalance has altered potassium levels. What knowledge does the nurse use to recognize that the potassium levels are altered in acid-base imbalances? Select one: a. In acidosis, hydrogen ions in the blood are exchanged for potassium from the cell. b. In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate. c. Potassium is returned to extracellular fluid on correction of metabolic acidosis. d. Hyperkalemia causes an alkalosis that results in potassium being shifted into the cell.
A
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? Select one: a. Inadequate protein intake b. Inadequate potassium intake c. Low calcium level d. Inadequate vitamin D intake
A
A client recovering from diabetic ketoacidosis asks the nurse how acidosis occurs. What is the best response? Select one: a. An insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones. b. Excess glucose in the blood is metabolized by the liver into acetone, which is acidic in nature. c. When an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. d. Insufficient insulin leads to cellular starvation, and as cells rupture, they release organic acids into the blood.
A
A client with type 1 diabetes has received diet instruction as part of his treatment plan. The nurse determines a need for additional instruction when the client makes which following comment? Select one: a. "I may eat whatever I want as long as I cover the calories with sufficient insulin." b. "I should eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." c. "I may have an occasional alcoholic drink if I include it in my meal plan." d. "I will need a bedtime snack because I take an evening dose of NPH insulin."
A
A few hours after returning to the surgical nursing unit, a client who has undergone a subtotal thyroidectomy develops numbness in the extremities. What intervention would the nurse anticipate? Select one: a. Administration of intravenous calcium gluconate b. Administration of intravenous morphine c. Endotracheal intubation with mechanical ventilation d. An immediate tracheostomy
A
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? Select one: a. Encouraging intake of approx. 2 L of fluid daily b. Giving the client a glass of soda before bedtime c. Taking the client to the bathroom twice per day d. Consulting with a dietitian
A
A nurse is caring for a client with type 2 diabetes and a necrotic right great toe who is scheduled for amputation of the affected toe. The client's white blood cell count is high-normal, and the client has coolness of the lower extremities, weighs 25 kg more than ideal body weight, and smokes two packs of cigarettes per day. Which nursing diagnosis addresses the primary factor affecting the client's ability to heal? Select one: a. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking. b. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking. c. Imbalanced nutrition: more than body requirements related to intake of high-fat, high carbohydrate foods. d. Ineffective health maintenance related to denial of the long-term effects of diabetes and smoking.
A
After 5 years of experiencing depression, fatigue, and lethargy, an older adult woman is diagnosed with hypothyroidism, and levothyroxine is prescribed. During initiation of thyroid replacement for the client, it is most important for the nurse to assess which of the following functions? Select one: a. Cardiovascular function b. Mental status c. Fluid and electrolyte balance d. Nutritional status
A
During a clinic visit 3 months following a diagnosis of type 2 diabetes, the client reports that she has been following her reduced-calorie diabetic diet, but she has not lost any weight, and she has neglected to bring her record of glucose monitoring results. What does the nurse recognize as the best indicator of the client's control of her diabetes since her initial diagnosis and instruction? Select one: a. A glycated (glycosylated) hemoglobin level (HbA1C) b. The client's verbal report of her symptoms c. Analysis for microalbuminuria d. A fasting glucose level
A
The family of a client who is unconscious following a stroke tells the nurse they feel "pressured" by the specialist to insert a feeding tube. They are reluctant to agree to the procedure because they believe this action is not something the client would want. Which of the following responses by the nurse illustrates ethical practice? Select one: a. "I can arrange for you to talk with the healthcare team about your loved one's situation." b. "You don't have to do what the specialist says. You should talk with the family health care provider" c. "Without advanced directives, you will not be able to prevent this intervention." d. "The medical team cannot force you to do anything you don't believe is right."
A
The nurse is providing care for a 73-year-old male client who has sought care because of a loss in his hearing acuity over the past several years. Which of the following statements is most accurate? Select one: a. Many people experience an age-related decline in their hearing b. This is often due to an infection that will resolve on its own c. You can likely accommodate for your hearing loss with a few small changes in your routine d. This is likely an effect of your medications; try stopping them for a few days
A
To decrease the risk for future hearing loss, which action should the nurse working with college students at the on-campus health clinic implement? Select one: a. Discuss the importance of limiting exposure to amplified music. b. Teach clients to regularly irrigate the ear to decrease cerumen impaction. c. Administer rubella immunizations to all students at the clinic. d. Arrange to include otoscopic examinations for all clients.
A
What should the nurse emphasize when teaching a client with type 1 diabetes about the Somogyi effect and dawn phenomenon? Select one: a. The Somogyi effect results in rebound hyperglycemia from too much insulin, and the dawn phenomenon results from decreased insulin the a.m. with counter-regulatory response. b. The Somogyi effect is characterized by hyperglycemia and the dawn phenomenon by hypoglycemia. c. The Somogyi effect occurs when the client is asleep, and the dawn phenomenon occurs after the client awakens. d. The Somogyi effect occurs early at night, and the dawn phenomenon occurs on arising.
A
A client with newly diagnosed type 2 diabetes asks the nurse what 'type 2' means in relation to diabetes. Which of the following statements is the best response to explain to the client how type 2 diabetes differs from type 1? Select one: a. "With type 2 diabetes, there are islet cell antibodies and insulin autoantibodies that destroy beta cells in the pancreas." b. "With type 2 diabetes, there is decreased insulin secretion and/or cellular/tissue resistance to insulin that is produced." c. "With type 2 diabetes, The body is totally dependent on an outside source of insulin." d. "With type 2 diabetes, the C-peptide chain of proinsulin secreted by the pancreas cannot be removed by the liver, resulting in a lack of active insulin."
B
A nurse is caring for an elderly asthmatic client who underwent a hernia repair six hours previously. The temperature of the client is 39.6oC, the pulse rate is 99/min, and the blood pressure is 100/70 mm Hg. What would be the most effective nursing intervention? Select one: a. Provide ice sponge baths to lower the temperature. b. Administer antipyretic drugs routinely. c. Maintain oxygen therapy. d. Provide cooling blankets to lower the temperature.
B
Following a thyroidectomy, the client develops hypoparathyroidism. The nurse teaches the client that maintenance therapy for the hypoparathyroidism will include which of the following? Select one: a. Parenteral parathyroid hormone b. Calcium supplements c. Phosphorus supplements d. A diet high in oxalic acid
B
For a client who is suspected of having a stroke, what is one of the most important pieces of information that the nurse can obtain? Select one: a. Time of the client's last meal b. Time at which stroke symptoms first appeared c. Client's hypertension history and management d. Family history of stroke and other cardiovascular diseases
B
Liver disease is characterized by decreased plasma proteins in the blood and obstruction of venous return to the heart. What does the nurse recognize that these two factors result in? Select one: a. Dehydration. The increased venous hydrostatic pressure forces more fluid through the kidney to be excreted. b. Edema. Both decreased plasma oncotic pressure and increased venous hydrostatic pressure cause movement of fluid into the interstitium. c. Vascular overload. Both the plasma oncotic pressure and the venous hydrostatic pressure are increased, keeping fluid in the vascular space. d. Normal fluid balance. Fluid movement is equalized by the decreased plasma oncotic pressure and the increased venous hydrostatic pressure.
B
The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit? Select one: a. Ensuring that the care team does not impose their beliefs on the family or the complementary practitioner. b. Ensuring any complementary therapies are safe when combined with his prescribed therapy. c. Identifying whether the family would prefer to pursue alternative or conventional treatment for their father. d. Taking measures to prevent cultural conflict when the practitioner comers to the hospital.
B
The normal body response to increased serum osmolality is release of: Select one: a. aldosterone from the adrenal cortex, which stimulates sodium excretion by the kidney b. ADH from the posterior pituitary, which stimulates the kidney to reabsorb water c. mineralocorticoids from the adrenal gland, which stimulate the kidney to excrete potassium d. calcitonin form the thyroid gland, which increases bone resorption and decreases serum Ca++
B
The nurse at the eye clinic advises all clients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of: Select one: a. exophthalmos. b. cataracts. c. anisocoria. d. glaucoma.
B
The nurse is assisting a client with a stroke who has homonymous hemianopia? The client will: Select one: a. Forget the names of foods. b. Eat food on only half of the plate. c. Have a preference for foods high in salt. d. Not be able to swallow liquids.
B
The nurse is planning care with a Mexican client who is diagnosed with depression. The client believes in "mal ojo" (the evil eye), and uses treatment by a root healer. The nurse should do which of the following? Select one: a. Explain that such beliefs are superstitious and should be forgotten. b. Involve the root healer in a consultation with the client, primary health care provider and nurse. c. Explain to the client that Western medicine has a scientific, not mystical, basis. d. Avoid talking to the client about the root healer.
B
Computed tomography (CT) of a 68-year-old male client's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department? Select one: a. Administration of tissue plasminogen activator (tPA) b. Positioning to promote cerebral perfusion c. Control of fluid and electrolyte imbalances d. Maintenance of the client's airway
D
If a client has decreased cardiac output caused by fluid volume deficit and marked vasodilation, what regulatory mechanism will increase the blood pressure by improving both of these? Select one: a. Stimulation of the sympathetic nervous system b. Secretion of prostaglandins PGE2 and PGI2 c. Release of antidiuretic hormone (ADH) d. Activation of the renin-angiotensin-aldosterone system
D
