synthesis secind quiz

9 240. A client has recently been diagnosed with type 1 diabetes. A glucose tolerance test is ordered. The order reads, "Administer glucose 1.0 g/kg." The client weighs 240 pounds. The nurse should administer: _____________________

109

12. A 49-year-old female is admitted to the hospital with a possible diagnosis of Addison's disease. An important nursing responsibility during a 24-hour-urine collection for the client suspected of having Addison's disease would be to: A. Assess the client for signs of edema B. Keep the client quiet and reduce stress C. Monitor the client for an elevation of blood pressure D. Restrict the client's fluid intake for the 24 hours

B

13. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which sign? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria

B

14. A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcus pneumonia is incontinent of feces and urine and is producing copious sputum. When providing care for this client the nurse's priority should be to: A. Wear goggles when suctioning the client's airway B. Use gown, mask, and gloves when bathing the client C. Use gloves to administer oral medications to the client D. Wear a gown when assisting the client with the bedpan

B

14. Treatment for Cushing's syndrome may involve removal of one of the adrenal glands, which could cause a temporary state of which condition? A. Hyperkalemia B. Adrenal insufficiency C. Excessive adrenal hormone D. Syndrome of inappropriate antidiuretic hormone (SIADH)

B

17. A client is brought into the emergency department with a brain stem contusion. Two days after admission, the client has a large amount of urine and a serum sodium level of 155 mEq/ dl. Which condition may be developing? A. Myxedema coma B. Diabetes insipidus C. Type 1 diabetes mellitus D. Syndrome of inappropriate antidiuretic hormone (SIADH)

B

2 A client is admitted with thromboembolic stroke. Which medication should be started by day 2? A. Acetaminophen B. Aspirin C. Tenecteplase D. Methylprednisolone

B

20. A client is admitted with Parkinson's disease. The client's face is expressionless and their speech is monotone. Which of the following observations by the nurse is most accurate? A. The client is most likely depressed and should be left alone. B. These are common symptoms of Parkinson's disease that produce an undesired facade of an alert and responsive individual. C. The client's antipsychotic medication may need to be adjusted. D. The client probably has dementia.

B

24. A client recalls smelling an unpleasant odor before his seizure. Which term describes this symptom? A. Atonic seizure B. Aura C. Icterus D. Postictal experience

B

26. A client who has had bone pains of insidious onset for four months is suspected of having multiple myeloma. The nurse understands that one of the diagnostic findings specific for multiple myeloma would be: A. Low serum calcium levels B. Bence-Jones protein in the urine C. Occult and frank blood in the stool D. Positive bacterial culture of sputum

B

29. Which statement shows that a client needs further teaching about the cause of an exacer- bation of systemic lupus erythematosus (SLE)? A. I need to stay away from sunlight." B. "I don't have to worry if I get a strep throat." C. "I need to work on managing stress in my life." D. "I don't have to worry about changing my diet."

B

30. To properly instill eardrops in a 28-year-old client with otitis externa, which method is correct? A. Pulling the pinna down and back B. Pulling the pinna up and back C. Pulling the tragus up and back D. Separating the palpebral fissures with a clean gauze pad

B

31. A client newly diagnosed with diabetic ketoacidosis has a serum glucose level of 485 mg/ dl. After treatment, the serum glucose level drops to 185 mg/ dl, and the cardiac moni- tor starts to show ventricular ectopic beats. Which factor is the most probablecause of the arrhythmia? A. Decreased serum chloride level B. Decreased serum potassium level C. Elevated serum glucose level D. Elevated serum sodium level

B

31. Which instruction given to a client after cataract surgery is inappropriate? A. "Avoid bending and straining." B. Avoid high-sodium foods to reduce intraocular pressure." C. "Don't drive or sleep on the affected side." D. "Don't use makeup on the affected eye."

B

34. When protective isolation isn't indicated, which activity is recommended for a client receiving chemotherapy? A. Bed rest B. Activity as tolerated C. Walk to bathroom only D. Out of bed for brief periods

B

43 When using a Snellen alphabet chart, a nurse records a client's vision as 20/40. Which statement best describes 20/40 vision? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision sees at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20 decrease in acuity in one eye, and 40 decrease in the other eye.

B

6 A 77-year-old client had a thromboembolic right stroke; his left arm is swollen. Which condition may cause swelling after a stroke? A. Elbow contracture secondary to spasticity B. Loss of muscle contraction decreasing venous return C. Deep vein thrombosis (DVI) due to immobility of the ipsilateral side D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus

B

8 When caring for a client with a diagnosis of diabetes insipidus, which nursing intervention should be the priority? A. Watching for signs and symptoms of septic shock. B. Maintain adequate fluid intake. C. Check weight every 3 days. D. Monitor urine for specific gravity greater than 1.030.

B

39. The nurse is reviewing a client's laboratory values. Which of the following is most consistent with a diagnosis of aplastic anemia? A. Decreased production of T-helper cells B. Decreased levels of white blood cells (WBCs), red blood cells (RBCs), and platelets C. Increased levels of WBCs, RBCs, and platelets D. Reed-Sternberg cells and lymph node enlargement

B Aplastic anemia is associated with pancytopenia-decreased level for all elements

49 When assessing the ability of a client's pupil to constrict, which cranial nerve (CN) is being tested? A. II B. III C. IV D. V

B II-visual acuity IV-movement Oh, Oh, Oh, To Touch And Feel Very Good Velvet. SUch Heaven. Olfactory-smell Optic-vision oculomotor=PERRLA trochlear=eye movement trigeminal=chewing, facial sensation abducens=movement of eyeball facial=taste, facial movement, salivation vestibulochochlear=hearing, balance glossopharyngeal=taste, swallow, salivation, sensation, chemo/baroreception vagus=speech, swallowing, sensation, chemo/baroreception spinal accessory=movement of shoulder hypoglossal=tongue

A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock, the nurse should: A. Prepare for a blood transfusion B. Notify the physician immediately C. Elevate the head of the bed 30 degrees D. Increase the liter flow of the oxygen being administered

B Septic shock!! Need to maintain fluids first. Need orders-antibiotics, IV fluids. If not perfusing well, put head down

16. Immediately after giving an injection, a nurse is accidentally stuck with the needle when a client becomes agitated. When is the best time for the employer to test the nurse for human immunodeficiency virus (HIV) antibodies to determine if she became infected as a result of the needle stick? A. Immediately and then again in 6 weeks B. Immediately and then again in 3 months C. In 2 weeks and then again in 6 months D. In 2 weeks and then again in 1 year `

B Want immediate bc want to know if nurse already has HIV. 6 weeks-can get false negatives

22. Which measure would be included in teachingthe client with multiple sclerosis (MS) to avoid exacerbation of the disease? A. Patching the affected eye B. Sleeping 8 hours each night C. Taking hot baths for relaxation D. Drinking 1.5 to 2 L of fluid daily

B exacerbations are due to stress, heat, fatigue

14. Frequent voiding of small amounts of urine after a lumbar laminectomy may indicate which condition? A. Diabetes insipidus B. Diabetic ketoacidosis C. Urine retention D. Urinary tract infection (UTI)

C

15. In addition to Pneumocystis carinii, a client with AIDS also has a 4cm leg ulcer. Considering the client's total health status, the most critical nursing diagnosis would be: A. Social isolation B. Impaired skin integrity C. Impaired gas exchange D. Imbalanced nutrition: less than body requirements

C

15. The nurse is teaching a client with hypothyroidism about the thyroid gland. Which of the following statements by the nurse would be the most accurate about which gland controls the secretion of thyroid hormone? A. Adrenal gland B. Parathyroid gland C. Pituitary gland D. Thyroid gland

C

19. A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which order should the nurse anticipate? A. Cardiac monitor, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels B. Prothrombin time CPT), partial thromboplastin time (P1T), fibrinogen, and fibrin split product values C. ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel D. EEG, alkaline phosphatase and aspartate aminotransferase levels,(liver panel), and basic serum metabolic panel

C

20. A Schilling test is ordered for a client who is suspected of having pernicious anemia. The nurse recognizes that the primary purpose of the Schilling test is to determine the client's ability to: A. Store vitamin BI2 B. Digest vitamin B12 C. Absorb vitamin BI2 D. Produce vitamin B12

C

21. A client with anemia may be tired due to a tissue deficiency of which substance? A. Carbon dioxide B. Factor VIII C. Oxygen D. T-cell antibodies

C

22. Which symptoms are classic for thrombocytopenia? A. Weakness and fatigue B. Dizziness and vomiting C. Bruising and petechiae D. Light-headedness and nausea

C

23. Which term describes involuntary, jerking, rhythmic movements of the eyes? A. Exophthalmos B. Diplopia C. Nystagmus D. Oculogyric crisis

C

25. If a pancreatitis attack has been brought on by gallstones or gallbladder disease, a client may require reinforcement about the need to follow which type of diet? A. High-calorie, high-protein diet B. High-fiber diet, encouraging fluid intake C. Low-fat diet, avoiding heavy meals D. Diet high in protein, calcium, and vitamin D

C

26. Which adverse effect may occur during phenytoin (Dilantin) therapy? A. Dry mouth B. Furry tongue C. Somnolence D. Tachycardia

C

27. Clients with insulin-dependent diabetes mellitus may require which change to their daily routine during periods of infection? A. No changes B. Less insulin C. More insulin D. Oral antidiabetic agents

C

29. The nurse is administering corticosteroid therapy to a client. The nurse should be alert for which of the following adverse effects of this therapy? A. Hyponatremia B. Hypoglycemia C. Change in metabolism D. Change in pituitary secretions

C

3 A client with hypothyroidism who experiences trauma, emergency surgery, or severe infection is at risk for developing which condition? A. Diabetes Insipidus B. Malignant hyperthermia C. Myxedema coma D. Thyroid storm

C

30. A previously healthy 70-year-old male client has a serum glucose level of 1,200 mg/ dl, a normal serum bicarbonate level, and urine free from acetone. The nurse should suspect which condition? A. Diabetic ketoacidosis (DKA) B. Diabetes insipidus C. Hyperglycemic hyperosmolar nonketotic coma D. Syndrome of inappropriate antidiuretic hormone (SIADH)

C

30. Which laboratory test result supports the diagnosis of systemic lupus erythematosus (SLE)? A. Elevated serum complement level B. Thrombocytosis, elevated sedimentation rate C. Pancytopenia, elevated antinuclear antibody (ANA) titer D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels

C

33. Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia? A. A client with brain injury B. A client with herniated nucleus pulposus C. A client with a high cervical spine injury D. A client with a stroke

C

36. A client, newly diagnosed as having type 1 diabetes, is encouraged to exercise on a regular basis primarily because exercise has been shown to: A. Decrease insulin sensitivity B. Stimulate glucagon production C. Improve the cellular uptake of glucose D. Reduce metabolic requirements for glucose

C

37. A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg; pulse, 34 beats/ minute; dry skin, and flaccid paralysis of the lower extremities. Which condition should be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis

C

38. A client with type 1 diabetes of long duration takes Humulin N and Humulin R insulin every morning. At noon, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. Two hours later, the client's serum glucose level drops to 30 mg/dl, and insulin coma is diagnosed. The nurse understands the reason for the development of acute hypoglycemia in this client is that: A. Glycogenolysis increased when lunch was not eaten after taking Humulin N insulin B. The stress brought on by the chest pain increases the use of serum glucose available to the client C. Glucose levels that are controlled by insulin drop more quickly than those controlled by oral antidiabetics D. The client's body became sensitive to the prescribed dose of insulin after long use, and the blood glucose level dropped erratically

C

40. Four hours after surgery, the blood glucose level of a client who has type 1 diabetes is elevated. The nurse should expect to: A. Administer an oral hypoglycemic B. Institute urine glucose monitoring C. Give supplemental doses of regular insulin D. Decrease the rate of the intravenous infusion

C

44 After a nurse instills atropine drops into both eyes for a client undergoing an ophthalmic examination, which instruction should be given to the client? A. "Be careful because the blink reflex is paralyzed." B. "Be aware that the pupils may be unusually small." C. "Wear dark glasses in bright light because the pupils are dilated." D. "Avoid wearing your regular glasses when driving."

C

45 Which procedure or assessment must a nurse perform when preparing a client for eye surgery? A. Clipping the client's eyelashes B. Verifying the affected eye has been patched for 24 hours before surgery C. Verifying the client has had nothing by mouth since midnight or at least 8 hours before surgery D. Obtaining informed consent

C

46 When teaching the client with Meniere's disease, which instruction should the nurse give about vertigo? A. "Report dizziness at once." B. "Drive in daylight hours only." C. "Get up slowly, turning the entire body." D. "Change your position using the logroll technique."

C

47 An l8-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which instruction? A. "Watch him for keyhole pupil for the next 24 hours." B. "Expect profuse vomiting for 24 hours after the injury." C. ''Wake him every hour and assess his orientation to person, time, and place." D. "Notify the physician immediately if he has a headache."

C

A client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? A. AB Rh-positive B. A Rh-positive C. A Rh-negative D. 0 Rh-positive

C

28. The nurse is caring for a client with an adrenal medulla tumor. Which of the following symptoms would the nurse expect to assess? A. Carpopedal spasm B. Hyperglycemia C. Hypertension D. "Moonface"

C Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with the other options.

31. According to a standard staging classification of Hodgkin's disease, which criterion reflects stage II? A. Involvement of extralymphatic organs or tissues B. Involvement of a single lymph node region or structure C. Involvement of two or more lymph node regions or structures D. Involvement of lymph node regions or structures on both sides of the diaphragm

C STAGE I- involvement of single lymph node stage II-involve 2 or more stage III-involve lymph nodes on both sides of diaphragm stage IV-involve extralymphatic organ

11. The nurse would expect the diagnostic studies of a client with Cushing's syndrome to show: A. Moderately increased serum potassium levels B. Increased numbers of eosinophils in the blood C. High levels of 17 -keto steroids in a 24-hour urine test D. Normal to low levels of adrenocorticotropic hormone (ACTH)

C This is a urinary metabolite of steroid hormones that are excreted in large amounts in hyperaldosteronism. Cushing=high level of ACTH/cortisol.=excess glucose, fat deposit, decreased amino acid finding: elevated 17-ketosteroids and gluc in urine high 17-hydroxycorticosteroids in plasma elevated gluc, WBC, RBC in serum

2 A client is scheduled to start an insulin regimen. Based on an understanding of peak effect times, which of the following insulin is prescribed to provide basal coverage? A. Insulin lispro B. Insulin aspart C. Novolin NPH D. Humalin R

C lispro-rapid onset and short duration aspart-rapid acing nph- 2-4 hr onset; 10-16 hr duration

36. Which intervention is stressed in teaching about multiple myeloma? A. Maintain bed rest. B. Enforce fluid restriction. C. Drink 3 qt (3 L) of fluid daily. D. Keep the lower extremities elevated.

C multiple myeloma-destruction of bone-high Ca in blood. Need fluids to flush out

A client with a right stroke has a flaccid left side. Which intervention would best prevent shoulder subluxation? A. Splint the wrist. B. Use an air splint. C. Put the affected arm in a sling. D. Perform range-of-motion exercises on the affected side.

C Subluxation- partial dislocation of shoulder

The same client has a hematocrit value of 25. The nurse should anticipate that the physician will order: A. Ringer's lactate B. Serum albumin C. Blood replacement D. High molecular dextran

C fluid vs blood. Hematocrit value is low.

6 During the progressive stage of shock, anaerobic metabolism occurs. The nurse must be aware that initially this causes: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C-lactic acid

When assessing for hemorrhage after a client has a total hip replacement, the most important nursing action would be to: C; if bleeding of hip, will see color change, and excruciating pain before ecchymosis. Measure the girth of the thigh Check the vital signs every four hours Examine the bedding under the client Observe for ecchymosis at the operative site

C; if bleeding of hip, will see color change, and excruciating pain before ecchymosis.

A client is admitted with a spinal cord injury at the level of Tl2. He has limited movement of his upper extremities. Which medication should be used to control edema of the spinal cord? Acetazolamide (Diamox) Furosemide (lasix) Methylprednisolone (Solu-MedroD Sodium bicarbonate

C=WANT TO GIVE STEROIDS

34. A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that the nurse's teaching has been effective? Select all that apply: A. "I have to take my steroids for 10 days." B. "I need to weigh myself daily to be sure I don't eat too many calories." C. "I need to call my physician to discuss my steroid needs before I have dental work." D. "I will call the physician if I suddenly feel profoundly weak or dizzy." E. "If I feel like I have the flu, I'll carryon as usual because this is an expected response." F. "I need to obtain and wear a medical alert bracelet."

CDF

13. For an adult client to be diagnosed with acquired immunodeficiency syndrome (AIDS), which condition must be present? A. Infection with human immunodeficiency virus (HIV), tuberculosis, and cytomeg- alovirus infection B. Infection with HIV, an alternative lifestyle, and a T-cell count above 200 cells/ul C. Cytomegalovirus infection, CD4+ count below 200 cells/ul, and a T-cell count above 400 cells/pl D. Infection with HIV, a history of acute HIV infection, and a CD4+ T-cell count below 200 cells/ul

D

15. When prioritizing care, which client should the nurse assess first? A. A 50-year-old client with diverticulitis B. A 17-year-old client 24 hours postappendectomy C. A 50-year-old client 3 days postmyocardial infarction D. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome

D

16. A client is admitted with Graves' disease. Which laboratory test should the nurse expect to be ordered? A. Serum glucose B. Serum calcium C. Lipid panel D. Thyroid panel

D

19. When evaluating the extent of Parkinson's disease, a nurse observes for which condition? A. Bulging eyeballs B. Diminished distal sensation C. Increased dopamine levels D. Muscle rigidity

D

19. Which method of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis? A. Subcutaneous B. I.M. C. I.V. bolus only D. I.V. bolus, followed by continuous infusion

D

20. Which electrolyte imbalance should a nurse be alert for in a client started on an insulin drip? A. Hypercalcemia B. Hypermagnesemia C. Hypophosphatemia D. Hypokalemia

D

21. Which disease process releases enough insulin to prevent ketosis but not enough to prevent hyperglycemia? A. Diabetes insipidus B. Diabetic ketoacidosis C. Type 2 diabetes mellitus D. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

D

22. A client presents to the emergency department with weakness, thirst, warmth and an inability to concentrate. His laboratory results are serum glucose 712 mg/ dl, urine negative for ketones, and minimal electrolyte imbalance. Which complication should the client be evaluated for? A. Hypoglycemia B. Diabetes insipidus C. Diabetic ketoacidosis (DKA) D. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

D

23. A client presents with a temperature of 1030 F (39.40 C), hypotension, dry mucus membranes, and a blood glucose level of 590 mg/ dl. Which of the following conditions would the nurse suspect for this client? A. Diabetes mellitus B. Diabetes insipidus C. Diabetic ketoacidosis D. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

D

25. A client with new-onset seizures of unknown cause is started on phenytoin (Dilantin), 750 mg IV. now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loadingdose? A. To prevent the need for surgical excision of the epileptic focus B. To ensure that the drug reaches the cerebrospinal fluid C. To reduce secretions in case another seizure occurs D. To more quickly attain therapeutic levels

D

27. What's the most importantconcern for clients who drink alcohol while taking phenytoin? A. Alcohol increases phenytoin activity. B. Alcohol raises the seizure threshold. C. Alcohol impairs judgment and coordination. D. Alcohol decreases the effectiveness of phenytoin.

D

28. A client with a C6 spinal injury would most likely have which symptom? A. Aphasia B. Hemiparesis C. Paraplegia D. Quadriplegia

D

32. The most common signs and symptoms of hypothyroidism include: A. increased body temperature, tachycardia, and fatigue. B. tachycardia, pitting, and facial edema. C. facial edema, weight gain, and diarrhea. D. cold intolerance, swollen hands and feet, and mental sluggishness.

D

33. A client with leukemia has neutropenia. Which function must be frequently assessed? A. Blood pressure B. Bowel sounds C. Heart sounds D. Breath sounds

D

34. When discharging a client from the hospital after a laminectomy, the nurse recognizes that the client needs further teaching when he makes which statement? A. "I'll sleep on a firm mattress." B. "I won't drive for 2 to 4 weeks." C. "When I pick things up, I'll bend my knees." D. "I can't wait to pick up my 1-year-old- granddaughter."

D

35. A nurse assesses a client who has episodes of autonomic dysreflexia. Which condition can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli

D

36. During an episode of autonomic dysreflexia in which a client becomes hypertensive, the nurse should perform which intervention? A. Elevate the client's legs B. Put the client flat in bed C. Put the bed in Trendelenburg's position D. Put the client in high Fowler's position

D

37. A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. The nurse should advise the client to: A. Avoid food, drink clear liquids, take a daily temperature, and stay in bed B. Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed C. Eat as much as possible, increase fluid intake, and call the office again the next day D. Take the oral hypoglycemic pill, drink warm fluids, and perform a serum glucose test ac and hs

D

38. A client has a cervical spine injury at the level of C5. Which condition should the nurse anticipate during the acute phase? A. Absent corneal reflex B. Decerebrate posturing C. Movement of only the right or left half of the body D. The need for mechanical ventilation

D

4 To maintain airway patency during a stroke in evolution, which nursing intervention is appropriate? A. Thicken all dietary liquids. B. Restrict dietary and parenteral fluids. C. Place the client on oxygen. D. Have tracheal suction available at all times.

D

42. Which method should be used to assess pupil accommodation? A. Touching the cornea lightly with a wisp of cotton B. Having the client follow an object upward, downward, obliquely, and horizontally C. Assessing for peripheral vision D. Observing for pupil constriction and convergence while focusing on an object coming toward the client

D

5 Which diet would be least likely to lead to aspiration in a client who had a stroke with residual dysphagia? A. Clear liquid B. Full liquid C. Mechanical soft D. Thickened liquid

D

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should observe for: Pallor and cyanosis Dyspnea on exertion A decreased hematocrit An elevated hemoglobin

D

The nurse is aware that nutritional support of a client's natural defense mechanisms would indicate the need for a diet high in: A. The essential fatty acids B. Dietary cellulose and fiber C. The amino acid, tryptophan D. Vitamins A, C, E, and selenium

D

16. A client is newly diagnosed with myasthenia gravis. The nurse is teaching the client about the cause of this disease. Which of the following responses by the client indicates that the teaching has been effective? A. A postviral illness characterized by ascending paralysis B. Loss of the myelin sheath surrounding peripheral nerves C. Inability of basal ganglia to produce sufficient dopamine D. Destruction of acetylcholine receptors causing muscle weakness

D postviral with paralysis-Guillain-Barre loss of myelin sheath- Multiple sclerosis insufficient dopamin- Parkinson's

17. Which blood test is used first to identify a response to human immunodeficiency virus (H1V) infection? A. Western blot B. CD4+ T-cell count C. Erythrocyte sedimentation rate D. Enzyme-linked immunosorbent assay (ELISA)

D Do Elisa first then confirm with western blot if is positive

21. To evaluate the effectiveness of levodopacarbidopa (Sinemet), a nurse should watch for which result? A. Improved visual acuity B. Decreased dyskinesia C. Reduction in short-term memory D. Lessened rigidity and tremor

D Dopamine promotor for Parkinson's

5 A client is scheduled for several tests. Which test should be performed after the thyroid function tests? A. Ultrasound of the carotid arteries. B. EEG. C. Chest X-ray. D. Computed tomography scan of the head with contrast.

D Iodine is essential to the normal function of the thyroid gland. However, too much iodine can cause either hyperthyroidism or hypothyroidism

28. A client receiving chemotherapy is considered at high risk for developing lysis syndrome. Which tests would the nurse expect to monitor for 48 to 72 hours after the infusion? A. Complete blood count, prothrombin time, and partial thromboplastin time B. Myoglobin, troponin, and creatine kinase C. Glucose, bilirubin, and alanine aminotransferase D. Electrolytes, blood urea nitrogen (BUN), and creatinine

D Lysis syndrome-when getting chemo, chemo kills the tumor and tumor lyse in the body. Body degrades the tumor and has to excrete it. Dialysis or dilution

18. A 20-year-old client with myasthenia gravis will undergo plasmapheresis. Which action describes the purpose of this procedure? A. Preventing exacerbations during pregnancy B. Removing T and B lymphocytes that attack acetylcholine receptors C. Delivering acetylcholinesterase inhibitor directly into the bloodstream D. Separating and removing acetylcholine receptor antibodies from the blood

D plasmapheresis- withdrawing blood, filtering it and giving back to the pt

18. Objectives for treating diabetic ketoacidosis (DKA) include administration of which treatment? A. Glucagon B. Blood products C. Glucocorticoids D. Insulin and IV fluids

D want to use glucose instead of ketones. So give insulin for cells to uptake glucose

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution. The I.V. is being infused via an infusion pump and the pump is currently set at 10 mllhour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number.

5

1. A client who is started on metformin and glyburide would have initially presented with which symptoms? A. Polydipsia, polyuria, and weight loss B. Weight gain, tiredness, and bradycardia C. Irritability, diaphoresis, and tachycardia D. Diarrhea, abdominal pain, and weight loss

A

11. A 19-year-old client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which laboratory finding is most consistent with DIC? A. Low platelet count B. Elevated fibrinogen levels C. Low levels of fibrin degradation products D. Reduced prothrombin time (PT)

A

12. The nurse knows that a positive diagnosis for HIV infection is made based on: A. Positive ELISA and Western blot tests B. A history of high-risk sexual behaviors C. Evidence of extreme weight loss and high fever D. Identification of an associated opportunistic infection

A

12. When evaluating an arterial blood gas from a client with a subdural hematoma, the nurse notes the Paco2, is 30 mm Hg. Which response best describes this result? A. Appropriate; lowering carbon dioxide (CO2) may reduce intracranial pressure (ICP) B. Emergent; the client is poorly oxygenated C. Normal D. Significant; the client has alveolar hypoventilation

A

13. Which intervention is the priority for a client with addisonian crisis? A. Preventing shock B. Preventing infection C. Relieving anxiety D. Lowering blood pressure

A

24. A 48-year-old client has been admitted with complaints of acute abdominal pain in the mid epigastric region, back tenderness, nausea, and vomiting. The nurse recognizes these findings to be associated with which condition? A. Acute pancreatitis B. Crohn's disease C. Hypophysectomy D. Pheochromocytoma

A

26. A client is in diabetic ketoacidosis, secondary to infection. As the condition progresses, which symptoms might the nurse see? A. Kussmaul's respirations and a fruity odor on the breath B. Shallow respirations and severe abdominal pain C. Decreased respirations and increased urine output D. Cheyne-Stokes respirations and foul smelling urine

A

27. The nurse understands that the most definitive test to confirm a diagnosis of multiple myeloma is: A. Bone marrow biopsy B. Serum test for hypercalcemia C. Urine test for Bence-Jones protein D. X-ray films of the ribs, spine, and skull

A

3 For a client with a stroke, which criterion must be fulfilled before the client is fed? A. The gag reflex returns. B. Speech returns to normal. C. Cranial nerves III, IV, and VI are intact. D. The client swallows small sips of water without coughing.

A

32. When teaching the family of a client with C4 quadriplegia how to suction his tracheostomy, the nurse includes which instruction? A. Suction for 10 seconds at a time. B. Regulate the suction machine to -300 cm suction. C. Apply suction to the catheter during insertion only. D. Pass the suction catheter into the opening of the tracheostomy tube ¾" to 1 ¼" .

A

39. A client with newly diagnosed diabetes indicates a hatred for asparagus, broccoli, and mushrooms. When reviewing the exchange list with the client, the nurse would know that the teaching about the exchange list was understood when the client states, "Instead of these foods I can eat: A. String beans, beets, or carrots." B. Corn, lima beans, or dried peas." C. Baked beans, potatoes, or parsnips." D. Corn muffins, corn chips, or pretzels."

A

39. The nurse is teaching a client who has a diagnosis of a stroke versus a transient ischemic attack (TIA). Which statement by the nurse describing to the client the difference between stroke and TIA would be the most accurate? A. TIAs resolve in less than 24 hours. B. TIAs may be hemorrhagic in origin. C. TIAs may cause a permanent motor deficit. D. TIAs may predispose the client to a myocardial infarction (MI).

A

48 A client is admitted with second stage Alzheimer's disease. In communicating with the client, which of the following techniques will be the most successful? A. Listening carefully and deciphering word substitutions B. Avoiding repeated messages, as this may agitate the client C. Avoiding yes or no questions D. Avoiding the subject-verb-object format

A

6 Adrenal insufficiency develops secondary to inadequate secretion of which pituitary hormone? A. Corticotropin B. Antidiuretic hormone (ADH) C. Follicle-stimulating hormone (FSH) D. Thyroid-stimulating hormone (fSH)

A

A client with esophageal varices is admitted with hematemesis, and two units of blood are ordered. Halfway through the first unit of blood the client complains of flank pain. The nurse's first action should be to: A. Stop the transfusion B. Obtain the vital signs C. Assess the pain further D. Monitor the hourly urinary output

A

After sustaining multiple internal injuries from being hit by a car, the client's blood pressure suddenly drops to 80/60 mm Hg. The nurse should realize that this is probably caused by: A reduction in the circulating blood volume Diminished vasomotor stimulation to the arterial wall Vasodilation resulting from diminished vasoconstrictor tone Cardiac decompensation resulting from electrolyte imbalance

A

23. Which explanation about the action of heparin should the nurse provide to a client who has just started being administered this drug? A. It slows the time it takes for the blood to clot. B. It stops the blood from clotting. C. It thins the blood. D. It dissolves clots in the arteries of the heart.

A thinning blood means giving volume to dilute blood to decrease hematocrit level

7 Clear fluid is draining from the nose of a client who had a head trauma 3 hours ago. This may indicate which condition? A. Basilar skull fracture B. Cerebral concussion C. Parietal skull fracture D. Sinus infection

A Clear fluid may mean CSF-common in basilar fracture Concussion-loss of consciousness sinus fracture- facial pain

35. Which substance has abnormal values early in the course of multiple myeloma? A. Immunoglobulins B. Platelets C. Red blood cells (RBCs) D. White blood cells (WBCs)

A Early=immunoglobulin Late=platelets, RBC, WBC

1. A client had an embolic stroke. Which condition places him at risk for thromboembolic stroke? A. Atrial fibrillation B. Bradycardia C. Deep vein thrombosis (DVT) D. History of myocardial infarction (MI)

A If a blood clot forms in the atria, it can be pumped out of the heart, to the brain, blocking off the blood supply to an artery in the brain, causing a stroke. WHen a pt is in a.fib, the heart beats 300 times a minute, increasing risk for clot to leave..

10 A client with head trauma develops a urine output of 300 ml/hour, dry skin, and dry mucous membranes. Which nursing intervention is the most appropriate to perform immediately? A. Evaluate urine specific gravity. B. Anticipate treatment for renal failure. C. Provide emollients to the skin to prevent breakdown. D. Slow the IV. fluids and notify the physician.

A Pt is in diabetes insipidus.

25. The nurse is teaching a client with systemic lupus erythematosus (SLE). Which response by the client indicates understanding about which tissues in the body are primarily attacked by SLE? A. Connective B. Heart C. Lung D. Nerve

A SLE_inflammation of connective tissue, primarily women. bc antibody-antigen complex trapped in organ capillaries-fibrinoid necrosis. joint pain, weight loss, photophobia, NC, butterfly rash, ulcerations

4 After a client is admitted with an adrenal malfunction, the nurse demonstrates an under- standing of the function of the adrenal gland by identifying which hormones as being released by the adrenal medulla? A. Epinephrine and norepinephrine. B. Glucocorticoids, mineralocorticoids, and androgens. C. Thyroxine, triiodothryonine, and calcitonin. D. Insulin, glucagon, and somatostatin.

A adrenal medulla releases E, NE adrenal cortex releases Glucocorticoids, mineralocorticoids, and androgens.

35. A client who suffered a brain injury after falling off a ladder has recently developed syn- drome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment he's receiving for SIADH is effective? Select all that apply: A. Decrease in body weight B. Rise in blood pressure; drop in heart rate C. Absence of wheezes in the lungs D. Increase in urine output E. Decrease in urine osmolarity

ADE

17. A client with suspected myasthenia gravis is to undergo a Tensilon test. Tensilon is used to diagnose-but not treat-myasthenia gravis. Why isn't it used for treatment? A. It isn't available in an oral form. B. With repeated use, immunosuppression may occur. C. Dry mouth and abdominal cramps may be intolerable adverse effects. D. The short half-life of Tensilon makes it impractical for long-term use.

d

40. Which precautions should the nurse include in the care plan for a neutropenic client with lymphoma? A. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. B. Put on a mask, gown, and gloves when entering the client's room. C. Provide a clear liquid, low-sodium diet. D. Eliminate fresh fruits and vegetables; avoid using enemas, and practice frequent hand washing.

d

41. A 40-year-old paraplegic client must perform intermittent catheterization of the bladder. Which instruction should be given? A. "Clean the meatus from back to front." B. "Measure the quantity of urine." C. "Gently rotate the catheter during removal." D. "Clean the meatus with soap and water."

d

10 The wife of a client who has had a resection of an aldosterone-secreting tumor of the adrenal glands says, "I hope this is the end of the problem and that my husband will be back to work soon." Based on an understanding of the health problem, the nurse should: A. Explain that surgery will affect a cure, and the left adrenal gland is functioning to meet the body's needs. B. Caution the wife against setting her expectations too high, since the outcome for this problem is variable. C. Advise the wife to investigate other occupational alternatives for her husband if he plans to return to work. D. Tell her that although her husband will require hormone supplements for the rest of his life, he should be able to work.

a

18. A nurse is reviewing the laboratory results of a client with anemia. In which blood component would she expect to see a reduced value? A. Erythrocytes B. Granulocytes C. Leukocytes D. Platelets

a

38. A 73-year-old client is about to receive a blood transfusion to treat severe anemia. She asks the nurse how long the procedure will take. Which of the following statements by the nurse is the most correct? A. No longer than 4 hours B. Around 8 hours C. At least 12 hours D. At least 24 hours

a

9 A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which circumstance? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).

b

11. Stool softeners are given after a repair of a cerebral aneurysm for which reason? A. To prevent constipation when osmotic diuretics are used B. To stimulate the bowel due to loss of nerve innervation C. To prevent straining, which increases intracranial pressure (ICP) D. To prevent the Valsalva maneuver, which may lead to bradycardia

c

24. A pregnant client arrives at the emergency department with abruptio placentae at 34 weeks' gestation. She is at risk for which blood dyscrasia? A. Thrombocytopenia B. Idiopathic thrombocytopenic purpura (ITP) C. Disseminated intravascular coagulation (DIC) D. Heparin-associated thrombosis and thrombocytopenia (HATT)

c

32. Which statement is correct about the rate of cell growth in relation to chemotherapy? A. Faster growing cells are less susceptible to chemotherapy. B. Nondividing cells are more susceptible to chemotherapy. C. Faster growing cells are more susceptible to chemotherapy. D. Slower growing cells are more susceptible to chemotherapy.

c

37. During discharge teaching for corticosteroids, the client asks the nurse what the drugs suppress. Which of the following responses by the nurse would be the most accurate? A. Sympathetic response B. Pain receptors C. Immune response D. Neural transmission

c

50 An 87-year-old client is admitted with a stroke. During the admission interview and assessment, his speech is slow, nonfluent, and labored. How should the nurse document this finding? A. Receptive aphasia B. Wernicke's aphasia C. Expressive aphasia D. Global aphasia

c

8 A 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which response by the nurse is appropriate? A. ''Your son had a mild concussion; acetaminophen is strong enough." B. "Aspirin is avoided because of the danger of Reye's syndrome in children or young adults." C. "Opioids are avoided after a head injury because they may hide a worsening condition." D. "Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP)."

c

After abdominal surgery a client develops internal hemorrhaging. During further assessments, the nurse should expect the client to exhibit: A. Polyuris B. Bradypnea C. Tachycardia D. Hypertension =want hypotension

c

7 A nurse is caring for a client following surgical ablation of the pituitary gland. Which condition must she be alert for? A. Addison's disease B. Cushing's syndrome C. Diabetes insipidus D. Hypothyroidism

c causes for DI- related to head trauma, brain tumors, or surgical ablation of the pituitary gland.