PRACTICE HESI

A health care provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning? a.) Gurgling sounds with each breath b.) Fine crackles at the base of the lungs c.) Cyanosis in the nailbeds of the fingers d.) Dry cough at increasingly frequent intervals

A Secretions in the upper airway produce gurgling sounds that interfere with the free flow of air with each breath. Oropharyngeal suction will not address fine crackles at the base of the lungs. Cyanosis can result from a variety of problems unrelated to the presence of secretions; suctioning should be done only when secretions are blocking the airway. For a dry cough, suctioning is not needed in the absence of accumulated oropharyngeal secretions

Which outcome indicates range-of-motion exercises have been effective for a child with juvenile idiopathic arthritis (JIA)? a.) The knees are more mobile. b.) The pedal pulses become stronger. c.) Subcutaneous nodules at the joints recede. d.) The child states that the pain is diminished.

A The exercises are done to preserve function by mobilizing restricted joints. Circulation is not affected by the arthritic process. Exercise does not affect the subcutaneous nodules in the joints. Exercises are done to restore joint function; they do not necessarily relieve pain.

Which type of vision problem would the nurse document when a client describes being able to see near objects clearly, but objects in the distance are blurry? a.) Myopia b.) Hyperopia c.) Presbyopia d.) Astigmatism

A This client is describing myopia, which is nearsightedness. Hyperopia is farsightedness. Presbyopia is the loss of accommodation, which causes an inability to focus on near objects. Astigmatism is an uneven curvature of the cornea, which causes distorted vision.

Which clinical manifestations would the nurse expect a client with hypothyroidism to exhibit? Select all that apply. One, some, or all responses may be correct. Cool skin Photophobia Constipation Periorbital edema Decreased appetite

Cool skin, constipation, periorbital edema, decreased appetite Rationale Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal The client has a urinary infection. Cool skin Photophobia Constipation Periorbital edema Decreased appetite Photophobia is associated with exophthalmos that occurs with hyperthyroidism

Which clinical indicators would the nurse expect to identify when assessing a client who has trigeminal neuralgia (tic douloureux)? Select all that apply. One, some, or all responses may be correct. Prolonged periods of sleep Hyperactivity Exhaustion and fatigue Excessive talkativeness Inadequate nutritional intake

Exhaustion and fatigue Inadequate nutritional intake Severe, constant pain; emotional stress; muscle tensing; and diminished nutritional intake can lead to exhaustion and fatigue. The movements associated with chewing and swallowing may precipitate a painful attack. Because clients are apprehensive and have pain, prolonged periods of sleep usually do not occur. Pain medications do not normally cause hyperactivity. The client may speak less for fear of precipitating an attack.

In addition to iron, which nutrients are necessary for red blood cell synthesis? Select all that apply. One, some, or all responses may be correct. Protein Calcium Vitamin C Vitamin D Carbohydrates

Protein, vitamin C Protein is essential for the synthesis of blood proteins, albumin, fibrinogen, and hemoglobin. Vitamin C (ascorbic acid) influences the removal of iron from ferritin (making more iron available for the production of heme) and influences the conversion of folic acid to folinic acid. Calcium, vitamin D, and carbohydrates are not involved in the synthesis of red blood cells.

Which clinical manifestations would the nurse expect to identify in a client with a diagnosis of Cushing syndrome? Select all that apply. One, some, or all responses may be correct Polyuria Truncal obesity Hypotension Sleep disturbance Thin arms and legs

Truncal obesity Sleep disturbance Thin arms and legs Truncal obesity is a key feature of Cushing syndrome. Sleep disturbance is caused by the altered diurnal secretion of cortisol. Thin arms and legs are caused by protein catabolism, which causes muscle wasting. Truncal obesity is caused by the overproduction of adrenal cortisol hormone associated with Cushing syndrome. Polyuria is associated with diabetes mellitus and primary aldosteronism, not Cushing syndrome. Hypertension, not hypotension, is associated with Cushing syndrome because of sodium and water retention.

Which finding would the nurse expect to identify in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis? a.) Ulnar drift b.) Heberden nodes c.) Swan-neck deformity d.) Boutonnière deformity

b.) Heberden nodes Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.

A client has a tentative diagnosis of primary biliary cirrhosis. Which skin change would the nurse expect to observe when performing a physical assessment? a.) Vitiligo b.) Hirsutism c.) Melanomas d.) Telangiectasia

d.) Telangiectasia Telangiectasia is a vascular lesion associated with cirrhosis; it is also thought to be related to increased estrogen levels. Vitiligo refers to patches of depigmentation resulting from destruction of melanocytes. Hirsutism is excessive growth of hair; with cirrhosis, endocrine disturbances result in loss of axillary and pubic hair. Melanomas refer to cancerous skin lesions; they are not associated with biliary cirrhosis.

Which interventions would the nurse include in the plan of care for a client with gastroesophageal reflux disease (GERD)? Select all that apply. One, some, or all responses may be correct. 1.) Encourage client to follow the prescribed treatment regimen. 2.) Keep the head of the bed elevated to approximately 30 degrees. 3.) Avoid placing the client in the supine position for 2 to 3 hours after a meal. 4.) Instruct the client to eat six small meals a day with the last just before bedtime. 5.) Instruct the client to take a proton pump inhibitor before the first meal of the day.

1,2,3 Clients should be encouraged to follow the prescribed regimen. Nursing care of the client includes keeping the head of the bed elevated to approximately 30 degrees and avoiding the supine position for 2 to 3 hours after meals. The client should avoid food and activities that cause reflux such as eating late at night. Proton pump inhibitors should be taken before the first meal of the day and are more common in treating peptic ulcer disease.

Which information will the nurse consider when planning care for a client with human immunodeficiency virus (HIV) who has been diagnosed with class 3 tuberculosis? Select all that apply. One, some, or all responses may be correct. 1.) Class 3 tuberculosis is a clinically active disease, which is contagious. 2.) Tuberculosis is the leading cause of mortality in clients infected with HIV. 3.)HIV-positive clients are more likely to have multidrug resistant tuberculosis. 4.) Individuals with HIV usually have high fevers with active tuberculosis infection. 5.) Persons with active tuberculosis are usually treated on an outpatient basis

1,2,5 Class 3 tuberculosis is a clinically active and contagious disease; it is diagnosed either with positive bacteriological studies, or with both a significant reaction to a tuberculin skin test and clinical or x-ray evidence of current disease. Tuberculosis is the leading cause of mortality in clients with HIV infection. Persons with active tuberculosis are usually treated on an outpatient basis, and this does not change based on the client's HIV status. Although clients with HIV are more likely to develop active tuberculosis, they are not more likely to develop multidrug resistant tuberculosis. Immunecompromised clients, such as individuals who are HIV positive, are less likely to have high fever because of a diminished inflammatory and immune response to infection.

A client with a chronic obstructive pulmonary disease (COPD) exacerbation is receiving oxygen at 2 L/minute per nasal cannula and has an oxygen saturation of 88% (0.88). Which action would the nurse anticipate taking next? a.) Increasing oxygen flow rate to 3 L/minute b.) Preparing for intubation and assisted ventilation c.) Administration of an inhaled rapid-acting bronchodilator d.) Continuing to monitor the client with no therapy change

A Because the client's oxygen saturation indicates hypoxemia, a higher flow rate of oxygen is needed. The nurse will continue to monitor the oxygen saturation and respiratory rate and depth, because some (but not all) clients with COPD will have a decrease in respiratory drive when oxygen saturation is in the 95% to 100% (0.95-1.00) range. Intubation and assisted ventilation is not indicated now, although it may be needed if higher oxygen flows fail to improve the client's oxygen saturation. Inhaled bronchodilators help open airways and are frequently used for clients with COPD exacerbation, but do not directly increase oxygen saturation. The nurse will continue to monitor the client, but a change in treatment is indicated because the client is hypoxemic.

Which clinical manifestations would the nurse expect for a client who has myasthenia gravis? a.) Blurred vision with episodes of vertigo b.) Tremors of the hands when lifting objects c.) Partial improvement of muscle strength with mild exercise d.) Involvement of distal muscles more than proximal muscles

A Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.

The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? a.) A 59-year-old who had a knee replacement b.) A 60-year-old who has bacterial pneumonia c.) A 68-year-old who had emergency dental surgery d.) A 76-year-old who has a history of thrombocytopenia

A Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.

Which component of nursing care is most important for a newborn with respiratory distress syndrome (RDS)? a.) Keeping the infant in a warm environment b.) Turning the infant frequently to prevent apnea c.) Tapping the infant's toes to stimulate deep breathing d.) Maintaining the infant's oxygen administration level at the same rate

A The infant is kept in a warm environment because any attempt by the infant's body to maintain body temperature further compromises physical status by increasing metabolic activity and oxygen demands. Turning the infant frequently will decrease the respiratory complications, but will not prevent apnea. Tapping the infant's toes will stimulate the infant to cry and increase oxygen demands. The amount of oxygen administered should vary with the infant's laboratory values.

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? a.) Black, tarry stools b.) Frequent nausea c.) Joining Alcoholics Anonymous d.) Pain that increases after meals

A The priority is black, tarry stools, which indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Nausea is a common symptom of gastritis but is not life threatening. Attempts to control alcoholism should be supported, but this is a long-term goal; assessment of bleeding takes priority. Investigation of bleeding takes priority; later the nurse should help identify irritating foods that may be increasing the pain after eating and are to be avoided.

The nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. Which clinical findings are associated with this disorder? Select all that apply. One, some, or all responses may be correct Anemia Diarrhea Hemoptysis Abdominal cramps Decreased white blood cells

Anemia Diarrhea Abdominal cramps Ulceration of the intestinal mucosa commonly occurs, causing blood loss and anemia. The inflammatory process tends to increase peristalsis, causing diarrhea, electrolyte imbalances, and weight loss. The inflammatory process tends to increase peristalsis, causing abdominal cramping and diarrhea. Coughing up blood from the respiratory tract (hemoptysis) is not associated with colitis. A decreased number of white blood cells (leukopenia) is not associated with colitis.

A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. Which is an important nursing action? a.)Checking for capillary refill b.) Encouraging increased fluid intake c.) Suctioning secretions from the airway d.) Administering a high concentration of oxygen

B Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they

A student with type 1 diabetes asks the nurse which hormone causes the blood glucose level to rise. Which hormone would the nurse report? a.) Insulin b.) Glucagon c.) Epinephrine d.) Adrenocorticotropic hormone (ACTH)

B Glucagon promotes liver glycogenolysis, resulting in the release of glucose into the blood. ACTH is not directly related to glycogenolysis; it is released from the anterior pituitary. Insulin production is not directly related to glycogenolysis; in healthy individuals the level of insulin will increase as the glucose level increases. Epinephrine is not directly related to glycogenolysis; it is released from the adrenal medulla and sympathetic nerve endings.

Which nursing intervention is anticipated for a client who has Guillain- Barré syndrome? a.) Providing a straw to stimulate the facial muscles b.) Maintaining ventilator settings to support respiration c.) Encouraging aerobic exercises to avoid muscle atrophy d.) Administering antibiotic medication to prevent pneumonia

B Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

Which clinical sign is the most important indication of an accurate degree of dehydration? a.) Dry skin b.) Weight loss c.) Sunken fontanel d.) Decreased urine output

B Loss of fluid as a result of dehydration is most objectively assessed by weighing the infants daily because total body water accounts for approximately 75% of an infant's body weight. One liter of fluid weighs approximately 2.2 lb (1 kg). Dry skin may be indicative of conditions other than dehydration. A sunken fontanel is a clinical sign of dehydration, but does not indicate the degree of dehydration and is not an accurate measurement of dehydration. Decreased urine output cannot always be measured accurately in infants and children who are not toilet trained.

A client with a fractured femur is being prepared for surgery. The client develops a sudden onset of cyanosis, tachycardia, dyspnea, and restlessness. Which action would the nurse take first? a.) Call the health care provider. b.) Administer oxygen by mask. c.) Obtain an oxygen saturation level. d.) Maintain the client in a semi-Fowler position.

B The client probably has a fat embolus; oxygen reduces the surface tension of the fat globules and reduces hypoxia. Oxygen should be administered before the health care provider is called. It is helpful to determine the client's oxygen saturation level, but the nurse needs to address the client's oxygenation needs first. The semi-Fowler position is preferred for a fractured femur. Placing the client in the high-Fowler position causes hip flexion and stresses the fractured femur. The Trendelenburg position will further compromise the client's respiratory status because the pressure of the abdominal organs against the diaphragm will limit expansion of the thoracic cavity. Maintaining the semi-Fowler position is important, but it will not address or treat the oxygenation needs.

Which action for nutritional needs would the nurse take for a depressed client who has been sitting alone in a chair most of the day and displays no interest in eating? a.) Stay with the client during meals. b.) Take the client to the dining room. c.) Bring the client a tray of finger foods. d.) Talk with the client about the importance of nutrition.

B The nurse would stay with the client during meals. Active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat. Finger foods are more effectively given to clients experiencing mania. Discussing the importance of nutrition is too passive an intervention for a depressed client and usually will not stimulate the client to eat.

A client has symptoms associated with salmonellosis. Which data are relevant for the nurse to obtain from the client's history? a.) Any rectal cancer in the family b.) All foods eaten in the past 24 hours c.) Any recent extreme emotional stress d.) An upper respiratory infection in the past 10 days

B The salmonella organism thrives in warm, moist environments; all foods eaten within the past 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

A client has a leaking thoracic duct after a radical neck surgery. The nurse expects that the postoperative plan of care will include which prescriptions? a.) A gastrostomy tube, a high-fat diet, and bed rest b.) A chest tube, total parenteral nutrition (TPN), and bed rest c.) A rectal tube, a low-fat diet, and increased activity d.) A nasogastric tube, a moderate-fat diet, and increased activity

B A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow. Bed rest is recommended because lymphatic flow increases with activity. A gastrostomy tube is not used because the client can eat and drink; a high-fat diet is contraindicated, but bed rest is recommended. A rectal tube has no relationship to the drainage of chyle from the thoracic area; a low-fat diet and bed rest are recommended. The nasogastric tube does not drain fluid from the thoracic area; a low-fat diet and bed rest are recommended. A low-fat diet of medium-chain triglycerides will reduce the production and flow of chyle

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes which statement? a.) 'We need to schedule regular hearing tests, even at this young age.' b.) 'Lying on the abdomen is prohibited, so we'll keep him in an infant seat.' c.) 'We know that some difficulty breathing is expected, so we'll position him upright.' d.) 'We'll use the elbow restraints you provided to keep him from putting his hands in his mouth.'

B After cleft palate repair, the child is allowed to lie on the abdomen, especially immediately after surgery; this will allow drainage of secretions from the mouth. Children with cleft palate have an increased risk of middle ear infections, which can result in hearing loss, so hearing tests are scheduled early and repeated periodically throughout childhood. Until the infant adjusts to breathing through the mouth, he may exhibit difficulty breathing after surgery; this seldom requires more than positioning and support. Elbow restraints may be prescribed to keep the child's hands

A client who is slightly overweight is preparing for discharge from the hospital after a cholecystectomy. Which is important for the nurse to include in teaching the client about nutrition? a.) Listing low-protein foods that may be included in the diet b.)Explaining that fatty foods may not be tolerated for several weeks c.) Teaching the importance of a low-calorie diet to promote weight reduction d.) Encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal

B Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder, the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. A low-protein diet is not necessary. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. Although vitamin C, vitamin A, and zinc are important, they are not the priority.

A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia. Which therapeutic course would the nurse expect the primary health care provider to explore with this client? a.) Intensive psychotherapy b.) Continued medical therapy c.) Surgical therapy (colectomy) d.) Diet therapy (low-residue, high-protein diet)

C If medical management fails, surgical therapy is the next logical choice because it removes the affected intestine. Psychotherapy might improve the client's ability to cope with the disease, but it will not solve the physical problems. Continued medical therapy and diet therapy are classic interventions that probably have been tried during prior exacerbations and have failed.

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. Which would the nurse teach the parents? a.)An ileal bladder will be necessary once the child is of school age. b.) An indwelling catheter offers the best hope for bladder management. c.) The child will probably require a program of intermittent straight catheterization. d.) The child will have to wear diapers for many years because bladder training is a slow process.

C Most children with spinal cord damage resulting from spina bifida can be managed successfully with a program of intermittent straight catheterization. An ileal bladder is not necessary because most of these children can be managed successfully with intermittent straight catheterization. An indwelling catheter is the least-desirable approach due to the risk of recurrent urinary tract infection. Stating that the child will have to wear diapers for many years is inaccurate and may be devastating to the parents.

A client asks the nurse what causes myasthenia gravis. Which description of pathology would the nurse use in response to the client? a.) A genetic defect in the production of acetylcholine (ACh) b.) An inefficient use of the neurotransmitter ACh c.) A decreased number of functioning acetylcholine receptor (AChR) sites d.) An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C One of the pathological changes is fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites. There is no genetic defect in the production of ACh; rather than a genetic cause, it is thought that myasthenia gravis has an autoimmune etiology. Although the defect is at the neuromuscular junction, it is not an inefficiency in the use of ACh, but a decrease in the number of receptor sites for ACh. AChE is inhibited by anticholinesterase medications used to treat myasthenia gravis, leaving more ACh available to the damaged or decreased ACh receptors.

When a client with blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and watery pink-tinged nasal drainage, which action will the nurse take? a.) Assist the client to the supine position with no pillow. b.) Have the client squeeze the lower nose for 10 minutes. c.) Send a specimen of the fluid to the laboratory for analysis. d.) Apply warm moist packs to the client's nose and eyes.

C Pink-tinged nasal drainage after blunt nasal trauma indicates a possible cerebrospinal fluid leak, and the fluid would be sent to the laboratory to check for glucose. Clients who have nasal trauma are maintained in an upright position to reduce swelling. Squeezing the lower nose would be done for nosebleed, but watery pink nasal drainage is not characteristic of epistaxis. Cold packs would be used to minimize swelling and bleeding.

The registered nurse teaches a 70-year-old client with kyphosis about self-care measures. Which statement made by the client indicates effective learning? a.) 'I should take warm baths.' b.) 'I should do isometric exercises.' c.) 'I should sit in supportive armchairs.' d.) 'I should position myself quickly.'

C Sitting in a supportive armchair provides support to the bony structures and prevents further deformity in a client with kyphosis. Cartilaginous degeneration is prevented by taking warm baths. Isometric exercises are indicated for clients with muscular atrophy. Clients with kyphosis have a shift in the center of gravity and should not move quickly.

A client develops gastric bleeding and is hospitalized. Which area would the nurse assess most closely during the history? a.) Usual dietary pattern b.) Recent travel to other countries c.) Medications taken routinely or recently d.) A change in the status of family relationships

C Some medications, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and prednisone, irritate the stomach lining and may cause bleeding with prolonged use. The client's usual dietary pattern is not the cause of gastric bleeding; it is important to ascertain dietary habits when teaching about diet therapy. Travel to other countries may be related to intestinal irritation, causing diarrhea and intestinal bleeding, not gastric bleeding. Although stress related to family relationships may play a part in the need for treatment, the use of some medications has a more direct relationship.

The nurse is providing immediate postoperative care to a client who underwent a right pneumonectomy. In which position would the nurse place the client? a.) Right or left side-lying b.) High-Fowler or supine c.) Supine or right side-lying d.) Left side-lying or low-Fowler

C Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it may be tiring for a postoperative client.

After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? a.) 'Lately I can only breathe well if I sit up.' b.) 'During the night I sometimes get the chills.' c.) 'I get a sharp, stabbing pain when I take a deep breath.' d.) 'I'm coughing up large amounts of thicker mucus for the past several days.'

C Tension is placed on the pleura at the height of inspiration and causes pain. The response 'Lately I can only breathe well if I sit up' is typical of heart failure. The response 'During the night I sometimes get the chills' may indicate a pulmonary infection. The response 'I'm coughing up large amounts of thicker mucus for the past several days' may indicate a pulmonary infection.

A 3-year-old child with nephrotic syndrome is admitted with ascites, oliguria, respirations of 40 breaths per minute, and a recent weight gain of 10 lb (4.5 kg). Which nursing intervention would the nurse provide to ease the child's respiratory difficulty? a.) Providing six small meals daily b.) Maintaining a well-ventilated room c.) Ensuring bed rest in the low-Fowler position d.) Administering oxygen at 2 L/min by way of nasal cannula

C The low-Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites, thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened respiration, which will further distress the child. Placing the child in a well-ventilated room will not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm, not lack of oxygen.

While questioning a rape victim, the nurse discovers that the victim does not remember anything related to the assault. Which is the most probable cause of the victim's memory loss? a.) The rape victim was using opioids. b.) The rape victim was using hallucinogens. c.) The rape victim was drugged with flunitrazepam. d.) The rape victim was under the influence of alcohol.

C Flunitrazepam, also known as Rohypnol and the 'date rape drug,' is a hypnotic drug that produces prolonged sedation and short-term memory loss. Opioids produce a state of euphoria by removing painful feelings and creating a pleasurable experience and a sense of success, accompanied by clouding of the consciousness and a dreamlike state. Hallucinogens are drugs that produce vivid hallucinations and euphoria. Alcohol is a depressant that reduces inhibitions against aggression and sexual acting out. Although opioids, hallucinogens, and alcohol may alter memory, Rohypnol is the most likely to cause short-term amnesia

Which clinical manifestations would the nurse identify when assessing a client with hypercalcemia? Select all that apply. One, some, or all responses may be correct. Muscle tremors Abdominal cramps Increased peristalsis Cardiac dysrhythmias Hypoactive bowel sounds

Cardiac dysrhythmias Hypoactive bowel sounds When the serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.

When educating a client with interstitial cystitis, which foods would the nurse mention are bladder irritants? Select all that apply. One, some, or all responses may be correct. Milk Nuts Citrus fruit Aged cheeses Soy-containing foods Green, leafy vegetables

Nuts Citrus fruits Aged cheese Nuts, citrus fruits, and aged cheeses irritate the bladder of some individuals. Milk, soycontaining foods, and green, leafy vegetables are not likely to irritate the bladder

The primary health care provider instructs the client to increase their intake of seafood and protein in the diet. Which rationale would prompt this instruction? a.) The client has vitiligo. b.) The client has hypothyroidism. c.) The client has diabetes mellitus. d.) The client has a urinary infection.

b.) The client has hypothyroidism Nutritional deficiencies as a result of inadequate diet, especially decreases in protein and iodine intake, may be a cause for certain endocrine disorders, such as hypothyroidism. To meet nutritional requirements, clients with hypothyroidism are instructed to increase the intake of seafood and proteins to 60 mg/day. Because of hypofunction of the adrenal gland, clients with skin pigmentation conditions, such as vitiligo, are mainly instructed to consume more water. To improve metabolism, clients with diabetes mellitus are advised to add high-fiber food to their diet. A client with a urinary infection may not be advised to add seafood and proteins to their diet.

Which treatment strategies would benefit a client diagnosed with chlamydia? Select all that apply. One, some, or all responses may be correct. Penicillin G Ceftriaxone Clotrimazole Doxycycline Azithromycin

Doxycycline Azithromycin Doxycycline and azithromycin are used to treat chlamydia. Penicillin G is used to treat syphilis. Ceftriaxone is used to treat gonorrhea. Clotrimazole is used to treat candidiasis.

The nurse is caring for clients on a medical-surgical unit and identifies that which client has the highest risk for developing a pulmonary embolism? a.) An obese client with leg trauma b.) A pregnant client with acute asthma c.) A client with diabetes who has cholecystitis d.) A client with pneumonia who is immunocompromised

A An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.

After a laryngectomy, a client experiences frequent coughing episodes and copious production of secretions. The nurse would explain that the symptoms are the result of which condition? a.) The irritation of the stoma as a result of the tracheostomy tube that is in place b.) The reaction of the mucous membranes to air that is dry and cool c.) An upper respiratory inflammation caused by allergies d.) An insufficient coughing and deep-breathing regimen

B Air is moisturized and warmed as it passes through the nasopharynx. With a laryngectomy this area is bypassed, and the tracheobronchial tree compensates by producing copious amounts of secretions. Irritation of the stoma by the tracheostomy tube will produce local irritation and a local response. Upper respiratory inflammation because of allergies is not a response to allergies, but to the stress of the air that is entering the tracheobronchial tract. The air is no longer warmed or humidified by passing through the nose. Insufficient coughing and deep breathing do not create a response of coughing.

Which instruction would the nurse provide to the client with hemiparesis who is learning to ambulate with a cane? a.) Shorten the stride of the unaffected extremity. b.) Lean the body toward the cane when walking. c.) Advance the cane simultaneously with the affected extremity. d.) Hold the cane in the hand on the side of the affected lower extremity.

C

The nurse providing immediate postoperative care to a client who had an abdominoperineal resection would assess for which clinical indicator of complications? a.) Blood in the nasogastric tube b.) Return of bowel sounds c.) Absence of output from the stoma d.) Bloody drainage on the abdominal and rectal dressings

D Bloody drainage on the abdominal or rectal dressings may indicate hemorrhage. Blood in the NG tube is expected immediately after surgery. Peristalsis will not return for several days. The colostomy will not function until peristalsis returns.

Which diet would the nurse anticipate for an infant with phenylketonuria? a.) Fat-free b.) Protein-enriched c.) Phenylalanine-free d.) Low-phenylalanine

D Because phenylalanine is an essential amino acid, it must be provided in quantities sufficient for the promotion of growth, but low enough to maintain a safe blood level. Phenylalanine is derived from protein, not fat. An enriched-protein diet contains increased amount of proteins, including phenylalanine, which should be ingested in limited amounts. Because phenylalanine is an essential amino acid, it cannot be totally removed from the diet.

The nurse gives a client with hepatitis A information about untoward signs and symptoms related to the disease. The nurse instructs the client to contact the primary health care provider if the client develops which symptom? a.) fatigue b.) Anorexia c.) Yellow urine d.) Clay-colored stools

D Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the health care provider about fatigue and anorexia because these symptoms are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

Which item would the nurse use to feed an infant born with a unilateral cleft lip and palate? a.) Plastic spoon b.) Cross-cut nipple c.) Parenteral infusion d.) Rubber-tipped syringe

D Because the infant with a cleft lip and palate is unable to form the vacuum needed for sucking, a rubber-tipped syringe or dropper is used. This allows formula to flow along the sides to the back of the mouth, minimizing the danger of aspiration. A spoon is ineffective because the infant's extrusion reflex will prevent fluid from entering the mouth. A cross-cut nipple may be used with some infants, but rapid flow is dangerous because it can cause aspiration. Feeding can be accomplished with the use of special equipment; intravenous fluids are not necessary

Which statement made by the client helps in distinguishing bacterial vaginosis (BV) from other vaginal infections? a.) 'I have painful urination.' b.) 'I have vaginal irritation.' c.) 'I have lower abdominal pain.' ' d.) I have a thin vaginal discharge with a fishy odor.'

D Bacterial vaginosis is manifested by a vaginal discharge with a characteristic fishy odor, which occurs due to the replacement of hydrogen peroxide producing lactobacillus with anaerobic bacteria. These anaerobes cause an increase in vaginal amines that lead to an alteration of the vaginal pH and cause the odor. Painful urination, vaginal irritations, and lower abdominal pain are common manifestations in other vaginal infections.

Which item would the nurse use to feed an infant after a cleft lip repair? a.) Preemie nipple b.) Nasogastric tube c.) Gravity-flow nipple d.) Rubber-tipped syringe

D A rubber-tipped syringe minimizes sucking and is not irritating to the suture line. Using a preemie nipple is an acceptable method of feeding before surgery. A nasogastric tube is unnecessary; the infant is hungry enough to feed. Using a gravityflow nipple is another method of feeding before surgery.

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential lifethreatening complication would the nurse assess the client after this surgery? a.) Infection caused by the excretion of feces b.) Injury caused by exposed intestinal mucosa c.) Altered bowel elimination caused by the ostomy d.) Limited water reabsorption caused by removal of intestine

D The continuous excretion of liquid feces may deplete the body of fluids and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.

Which findings would be present in a client who has fat embolism syndrome? Select all that apply. One, some, or all responses may be correct. Decreased PaO 2 Increased platelet count Lipids in the urine Decreased hematocrit level Decreased prothrombin time

Decreased PaO2 Lipids in urine Decreased hematocrit levels The diagnostic abnormalities present in a client with fat embolism syndrome are decreased PaO , increased fat cells in urine, decreased hematocrit level, decreased platelet count, and prolonged prothrombin time.

When a client with chronic obstructive pulmonary disease (COPD) is receiving oxygen, which assessment findings indicate increasing carbon dioxide (CO ) retention? Select all that apply. One, some, or all responses may be correct. Anxiety Drowsiness Irregular pulse Mental confusion Increased respirations

Drowsiness Irregular pulse Mental confusion Because high oxygen saturation and high PaO levels can depress respiratory drive in some (but not all) clients with COPD, the nurse will plan to assess for clinical manifestations of CO retention when clients are receiving supplemental oxygen. CO retention depresses the central nervous system, leading to drowsiness, confusion, and decreased respiratory depth and rate. CO retention also affects cardiac function, leading to dysrhythmias. Lethargy, rather than anxiety, is seen with CO retention because of central nervous system depression. Respiratory rate will decrease with CO retention because of central nervous system depression.

Which infections would the nurse monitor for in the toddler based on structural characteristics at this age? Select all that apply. One, some, or all responses may be correct. Bronchiolitis Ear infection Acute sinusitis Laryngotracheobronchitis Inflammation of the tonsils

Ear infection Acute sinusitis Inflammation of the tonsils The toddler remains at risk for ear infection (otitis media), acute sinusitis, and inflammation of the tonsils or tonsillitis; therefore the nurse would assess the client for these infections due to the angle of the eustachian tube in the ear. Bronchiolitis and laryngotracheobronchitis (croup) are more common during infancy.

The nurse finds that the client has normal knees with a space between the client's medial malleoli of 4.5 cm. Which conditions could cause this finding? Select all that apply. One, some, or all responses may be correct. Arthritis Poliomyelitis Cerebral palsy Congenital deformity Peroneal nerve injury

Arthritis Poliomyelitis Congenital deformity The presence of normal knees and a medial malleoli space of 4.5 cm indicates a valgus deformity (knock-knees). A client with knock-knees may have arthritis, poliomyelitis, or a congenital deformity. A client with a spastic gait characterized by jerky, uncoordinated, and cross-knee movement may have cerebral palsy. A client with steppage gait may have a neurogenic disease such as peroneal nerve injury.

Which action would the nurse take first when a client with heart failure has an episode of paroxysmal nocturnal dyspnea (PND)? a.)Assess the client's oxygen saturation level. b.) Assist the client to sit on the edge of the bed. c.) Ask whether the client is experiencing chest discomfort. d.) Offer the client an explanation about the cause of the PND

B Because PND is caused by reabsorption of fluid from dependent body areas when the client lies flat, sitting on the edge of the bed will decrease venous return and improve the ability to take deep breaths. The oxygen saturation level would be assessed, but the first action would be to relieve the dyspnea by helping the client sit up. Because the client may have coronary artery disease, it is appropriate to ask about chest pain, but only after taking action to improve the respiratory status. An explanation about the causes of PND may be needed once the client is able to breathe more easily and may be receptive to teaching.

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? a.) Humidified oxygen is saturated with fluid. b.) The tracheostomy tube interferes with effective coughing. c.) The inner cannula of the tracheostomy tube irritates the mucosa. d.) The weaning process increases the amount of respiratory secretions.

B Because the tracheostomy tube enters the trachea below the glottis, the client is unable to close the glottis to retain air in the lungs; this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough. Humidified oxygen decreases the need for suctioning because it liquefies secretions, which then are easier to expel. The outer, not inner, cannula of a tracheostomy tube irritates the mucosa. Weaning begins when the respiratory status improves and the amount of respiratory secretions subsides.

An adolescent has been admitted with a history of symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. Which is the best intervention at this time? a.) Implementation of corticosteroids b.) Education about diet, rest, and exercise c.) Sun avoidance and calcium supplements d.) Avoidance of destructive coping mechanisms

B Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent. Corticosteroids may not be used until other therapies are unsuccessful. Although sun avoidance and calcium supplements may be helpful, they are not most important. Avoidance of negative coping strategies may be helpful if they are noted, but control over diet, rest, and exercise is a positive coping strategy.

Which information would the nurse expect the client who has multiple sclerosis with hand tremors to report? a.) The tremors increase when I fall asleep. b.) The tremors increase when I feel fatigued. c.) The tremors increase when I become nervous. d.) The tremors increase when I perform an activity

D Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.

The nurse is caring for a client 36 hours after the insertion of a chest tube. The tube is attached to a three-chamber, closed-chest drainage system. The nurse identifies that the water in the underwater seal tube is not fluctuating. Which action should the nurse take? a.) Take the client's vital signs. b.) Inform the health care provider. c.) Turn the client to the unaffected side. d.) Check the tube to ensure that it is not kinked.

D Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the health care provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.

During the infusion of dialysate during peritoneal dialysis, the client exhibits symptoms of severe respiratory difficulty. Which action would the nurse take? a.) Slow the rate of the client's infusion. b.) Place the client in a low-Fowler position. c.) Auscultate the client's lungs for breath sounds d.) Drain the fluid from the client's peritoneal cavity.

D Pressure from the dialysate may cause upward displacement of the diaphragm; the dialysate should be drained from the peritoneal cavity. Additional fluid, even at a decreased rate of infusion, will aggravate the respiratory difficulty. The client should already be in the semi-Fowler position. Auscultation is important, but it does not alleviate the respiratory difficulty.

Which clinical findings would the nurse expect when assessing a client with Cushing syndrome? Select all that apply. One, some, or all responses may be correct. Lability of mood Slow wound healing A decrease in the growth of hair Ectomorphism with a moon face An increased resistance to bruising

Lability of mood Slow wound healing Excess adrenocorticoids cause emotional lability, euphoria, and psychosis. Hypercortisolism impairs the inflammatory response, slowing wound healing. Increased secretion of androgens results in hirsutism (increase in growth of hair). Although a moon face is associated with corticosteroid therapy, ectomorphism is a term for a tall, thin, genetically determined body type and is unrelated to Cushing syndrome. There is increased bruising because capillary fragility results in multiple ecchymotic areas.

Which findings would the nurse expect when completing an admission physical for a client with a diagnosis of Parkinson disease? Select all that apply. One, some, or all responses may be correct. Muscle rigidity Blank facial expression Leaning toward the affected side Intention tremors with movement Hyperextension of the affected extremity

Muscle rigidity Blank facial expression With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (cerebrovascular accident [CVA]). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.

Which clinical findings would the nurse expect to see when assessing a client with hyperthyroidism? Select all that apply. One, some, or all responses may be correct. Dry skin Weight loss Tachycardia Restlessness Constipation Exophthalmos

Weight loss Tachycardia Restlessness Exophthalmos Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema. Dry, coarse, scaly skin occurs with hypothyroidism, not hyperthyroidism, because of decreased glandular function. Smooth, warm, moist skin occurs with hyperthyroidism. Constipation is associated with hypothyroidism. Increased stools and diarrhea are associated with hyperthyroidism.