Symptom Management NCLEX

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1.Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.2.Notify the HCP for an order for an antifungal swish-and-swallow medication.3.Have the client gargle with an antiseptic-based mouthwash several times a day.4.Determine what types of food the client has been eating for the last 24 hours

"1.This client probably has oral candidiasis, afungal infection of the mouth and esophagus. Brushing the teeth and patchy areas will not remove the lesions and will cause considerable pain. 2.(CORRECT) This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition. 3.Antiseptic-based mouthwashes usually contain alcohol, which would be painful for the client.4.The foods the client has eaten did not cause this condition. TEST-TAKING HINT: The client is complaining of a "sore mouth." The test taker must notice all the important information in the stem before attempting to choose an answer. How are brushing the area, an antiseptic mouthwash, or the foods that have been eaten going to alleviate the pain"

"The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, ""What good will it do? I will never be free of this pain."" Which statement is the nurse's best response? "1) ""Are you afraid of the pain never going away?"" 2) ""The pain clinic will give you medication to cure the pain."" 3) ""Pain clinics work to help you achieve relief from pain."" 4) ""I'm not sure. You should discuss this with your HCP."""

"Answer 3 is correct: 1) This is a therapeutic response and the client is requesting information. 2) Pain clinics do not cure pain; The do identify measures to help relieve pain. 3) Pain clinics use a variety of methods to help the client to achieve relief from pain. Some measures include guided imagry, transcutaneous electrical nerve stimulation (TENS) units, nerve block surgery or injections, or medications. 4) This is not an appropriate answer, even if the nurse is not sure. The nurse should attempt to discover the information for the client then give factual information."

"A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)? "a. White, cottage cheese-like patches on the tongue b. Yellow tooth discoloration c. Red, open sores on the oral mucosa d. Rust-colored sputum"

"Answer C. The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese-like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia."

"The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 x 10^6/mm^3, WBC count 150 x 10^3/mm^3, K+ 3.8 mEq/L, and Na+ 139 mEq/L. Based on these results, which intervention should the nurse teach the client? "A. Encourage the client to eat foods high in iron. B. Instruct the client to use an electric razor when shaving. C. Discuss the importance of limiting sodium in the diet. D. Instruct the family to limit visits to once a week."

"Answer: B Rationale: A. The anemia that occurs in leukemia is not related to iron deficiency, and eating foods in iron will not help. B. The platelet count of 22 x 10^3/mm^3 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count of less than 100,000. The client is at high risk for bleeding. Bleeding precautions include decreasing the risk by using soft-bristle toothbrushes and electric razors and holding all venipuncture sites for a minimum of 5 (five) minutes. C. The sodium level is within normal limits. D. Yes the client is at risk for an infection, but unless a family member is ill, they should be encouraged to visit whenever possible."

"A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about "a. treatment with antifungal agents. b. a change in antiretroviral therapy. c. foods that are higher in protein. d. the benefits of daily exercise"

"B Rationale: A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem"

"The client diagnosed with ARF is admitted to the ICU and placed on a therapeutic diet. Which diet is most appropriate for the client? "1. A high potassium and low calcium diet 2. A low-fat and low-cholesterol diet 3. A high cardohydrate and restricted-protein diet 4. A regular diet with 6 small feedings a day"

"Correct Answer: 3 1. The diet is low in K+, and Ca is not restricted in ARF 2. This is a diet recommended for clients with cardiac disease and atherosclerosis 3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products 4. The client must be on a therapeutic diet, and small feedings are not required"

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? "a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure"

"Correct answer: B Acute renal failure caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute renal failure is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute renal failure from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure."

In assessing the patient with stress incontinence, the nurse should anticipate which of these signs or symptoms? "A. Pain on urination B. A brownish urethral discharge C. Voiding excessive amounts of urine D. Loss of urine when laughing, coughing, or sneezing"

"Correct Answer: D. Loss of urine when laughing, coughing, or sneezing Rationale: Stress incontinence is the involuntary loss of urine when intra-abdominal pressure is increased, such as during coughing or laughing."

"During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply. "1. providing for patient comfort 2. preventing infection 3. providing adequate nutrition for healing to occur 4. splinting, positioning, and exercising affected joints 5. assessing home maintenance management"

"Correct: 1,2,3,4 Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints. Assessment of home maintenance management is an important goal in the rehabilitative stage, not the acute stage."

"The client diagnosed with septicemia has the following health-care provider orders. Which order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.

"Correct: 2 1.)The client's diet is not priority when transcribing orders. 2.)An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order. 3.)Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock.4.)There is no indication that this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia. TEST-TAKING HINT: Remember if the test taker can rule out two answers—"1" and "4"—and cannot determine the right answer between "2" and "3," select the option that directly affects or treats the client, which would be the antibiotics. Diagnostic tests do not treat the client."

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action of the nurse is to? 1. Discontinue dialysis and notify HCP 2. Monitor VS Q15 min for the next hour. 3. Continue dialysis at a slower rate after checking the lines for air. 4. Bolus the client with 500 ml of NS to break up the embolus.

1. If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the HCP, and administer O2 as needed.

"Which of the following medication prescriptions to help relieve discomfort in a child with leukemia should the nurse question? "1. Hydromorphone (Dilaudid) 2. Acetaminophen with codeine (Tylenol with Codeine) 3. Ibuprofen (Motrin) 4. Acetaminophen with Hydrocodone (Lortab)"

Answer 3: Ibuprophen prolongs bleeding timeand is contraindicated in clients with leukemia. Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen (Tylenol), may be prescribed to control pain and may be used in combination with codeine or hydrocodone if pain is more severe. Hydromorphone may also be used for severe pain.

An infant is admitted to the pediatric unit with a diagnosis of sepsis. the nurse is completing a nursing assessment. what would be the priority nursing assessment for this infant? 1. skin integrity 2. temperature 3. jaundice 4. respiratory function

Correct #4. RATIONALE: altered temerature, jaundice, and respiratory distress are all symptoms of sepsis in infancts. respiratory function is the highest priority because without an adequate airway and breathing, the client cannot maintain life. skin inetgrity is a routine assessment. STRATEGY: use the ABCs and the process of elimination to make a selection. airway and breathing typically take priority in situations of high acuity, such as sepsis.