Take Home Quiz 2 Review
. A client has been admitted to the medical unit with a diagnosis of ureteral colic, secondary to urolithiasis. When performing the client's admission assessment, the nurse may assess what signs and symptoms that are characteristic of this diagnosis? SELECT ALL THAT APPLY a) Hematuria b) Diarrhea c) Urinary frequency d) Acute pain e) High fever
A) hematuria C) urinary frequency D) acute pain Rationale: Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the client has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation and a fever is usually absent due to the noninfectious nature of the health problem.
A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? a) Highly dilute urine b) Albumin in the urine c) Glucose in the urine d) Leukocytes in the urine
A) highly dilute urine Rationale: Clients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but would indicate a urinary tract infection, if present in the urine.
A nurse is planning the care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this woman's care needs? a) ineffective role performance related to pain b) unilateral neglect to neuropathic pain c) risk for infection related to tissue alterations d) risk for impaired skin integrity related to myalgia
A) ineffective role performance related to pain Rationale: Typically, clients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a client's ability to perform normal roles and functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.
A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? SELECT ALL THAT APPLY a) insect stings b) autoimmunity c) foods d) medications e) environmental pollutants
A) insect stings C) foods D) medications Rationale: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.
The nurse care plan for a client with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care? a) Keep the client's bed linens free of wrinkles. b) Provide the client with snug clothing at all times. c) Provide total parenteral nutrition (TPN). d) Maximize the client's fluid intake.
A) keep the client's ned linens free of wrinkles Rationale: Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.
The nurse is caring for a client at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply. a) Pallor b) Rapid respiratory rate c) Epistaxis d) Bounding pulse e) Hypotension
A) pallor B) rapid respiratory rate E) hypotension Rationale: The client at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse's assessment reveals a BP of 98/52 mm Hg. The nurse should recognize that the client's kidneys will compensate by secreting what substance? a) Renin b) Antidiuretic hormone (ADH) c) Aldosterone d) Angiotensin
A) renin Rationale: When the vasa recta detect a decrease in BP, specialized juxtaglomerular cells near the afferent arteriole, distal tubule, and efferent arteriole secrete the hormone renin. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II. The vasoconstriction causes the BP to increase. The adrenal cortex secretes aldosterone in response to stimulation by the pituitary gland, which in turn is in response to poor perfusion or increasing serum osmolality. The result is an increase in BP.
A client is vigilant in her efforts to "take good care of herself" but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the client's lifestyle may have a negative effect on immune response? a) The client works out at the gym twice daily. b) The client sleeps approximately 6 hours each night. c) The client does not eat red meats. d) The client takes over-the-counter (OTC) dietary supplements.
A) the client works out at the gym twice daily Rationale: Rigorous exercise or competitive exercise—usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response. The client's habits around diet and sleep do not present obvious threats to immune function.
A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). What laboratory tests are most useful in diagnosing this rheumatic disorder? SELECT ALL THAT APPLY a) C-reactive protein b) Erythrocyte sedimentation rate c) Creatinine clearance d) D-dimer e) Erythrocyte count
A) C-reactive protein B) Erythrocyte sedimentation rate Rationale: Simultaneous elevation in the ESR and CRP has a sensitivity of 88% and a specificity of 98% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful.
A nurse on the renal unit is caring for a client who will soon begin peritoneal dialysis. The family of the client asks for education about the peritoneal dialysis catheter that has been placed in the client's peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? SELECT ALL THAT APPLY. a) The cuffs provide a barrier against microorganisms. b) The cuffs absorb dialysate. c) The cuffs stabilize the catheter. d) The cuffs are made of Dacron polyester. e) The cuffs prevent the dialysate from leaking.
A) the cuffs provide a barrier against C) the cuffs stabilize the catheter D) the cuffs are made of Dacron polyester E) the cuffs prevent the dialysate from leaking Rationale: Most of these catheters have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. They do not absorb dialysate.
A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what? a) 50 mL b) 30 mL c) 125 mL d) 100 mL
B) 30 mL Rationale: A urine output below 0.5 mL/kg/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.
An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? a) Immune complex (type III) b) Anaphylactic (type 1) c) Cytotoxic (type II) d) Delayed-type (type IV)
B) Anaphylactic (type 1) Rationale: he most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.
A client with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? a) change the dressing over the vascular access site at least every 12 hours b) assess for a thrill or bruit over the vascular access site each shift c) ensure that the client moves the extremity with the vascular access site as little as possible d) utilize the vascular access site for infusion of iV fluids
B) access for a thrill or bruit over the vascular access site each shift Rationale: The bruit, or "thrill," over the venous access site must be evaluated at least every shift. Frequent dressing changes are unnecessary and the client does not normally need to immobilize the site. The site must not be used for purposes other than dialysis.
A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? a) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN. b) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. c) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. d) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN.
B) administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. Rationale: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is given for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.
A client with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? a) Oral temperature b) Blood glucose c) Weight d) Assessment of urine for blood
B) blood glucose Rationale: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The client's blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.
. A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action? a) Assess the client's appetite b) Explain the process clearly to the client c) Apply topical anesthetic to the client's nares as prescribed d) Assist the client into a supine position
B) explain the process clearly to the client Rationale: The process should be explained to the client before removal. A client should not normally be supine with an NG tube in place and anesthetic is not normally prescribed. Removal is not contingent on the client's appetite.
A gerontologic nurse is caring for an older adult client who has a diagnosis of pneumonia. What age-related change increases older adults' susceptibility to respiratory infections? a) Decreased diaphragmatic muscle tone b) Impaired ciliary action c) Bronchial stenosis d) Atrophy of the thymus
B) impaired ciliary action Rationale: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.
The nurse is creating an education plan for a client who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan? a) Techniques for preventing metastasis b) Inspection and care of the incision c) The importance of increased fluid intake d) Signs and symptoms of rejection
B) inspection and care of the incision Rationale: The nurse teaches the client to inspect and care for the incision and perform other general postoperative care, including activity and lifting restrictions, driving, and pain management. There would be no need to teach the signs or symptoms of rejection as there has been no transplant. Increased fluid intake is not normally recommended and the client has minimal control on the future risk for metastasis.
A client is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? a) prime the tubing with 20mL of normal saline b) keep the vent lumen above the client's wait c) have the client pin the tube to the thigh d) maintain the client in a high Fowler position
B) keep the vent lumen above the client's waist level Rationale: The blue vent lumen should be kept above the client's waist to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way anti-reflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, the nurse does not prime the tubing, maintain the client in a high Fowler position, or have the client pin the tube to the thigh.
A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? a) Use antihistamines daily throughout the year. b) Modify the environment to reduce the severity of allergic symptoms. c) Teach the client to take deep breaths and cough frequently. d) Teach the client to seek medical attention at the first sign of an allergic reaction
B) modify the environment to reduce the severity of allergic symptoms Rationale: The client is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions is anaphylaxis. Overuse of antihistamines reduces their effectiveness.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? a) Returning acid to the body's circulation b) Returning bicarbonate to the body's circulation c) Excreting bicarbonate in the urine d) Sequestering free hydrogen ions in the nephrons
B) returning bicarbonate to the body's circulation Rationale: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.
A client with rheumatic disease has developed a gastrointestinal bleed. The nurse caring for the client should further assess the client for the adverse effects of what medications? a) Antimalarials b) Salicylate therapy c) Corticosteroids d) Immunomodulators
B) salicylate therapy Rationale: GI bleeding is an adverse effect that is associated with salicylates. Steroids, antimalarials, and immunomodulators do not normally have this adverse effect.
A nurse is providing care for a client who has a rheumatic disorder. The nurse's comprehensive assessment includes the client's mood, behavior, LOC, and neurologic status. What is this client's most likely diagnosis? a) rheumatoid arthritis (RA) b) systemic lupus erythematosus (SLE) c) osteoarthritis (OA) d) gout
B) systemic lupus erythematosus (SLE) Rationale: SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The client and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.
A client has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? a) Half the width of the stoma b) The widest part of the stoma c) The narrowest part of the stoma d) The circumference of the stoma
B) the widest part of the stoma Rationale: The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.
The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? SELECT ALL THAT APPLY a) Placing clients in negative pressure isolation rooms b) Using safe injection practices c) Using appropriate personal protective equipment d) Performing hand hygiene
B) using safe injection practices C) using appropriate personal protective equipment D) performing hand hygiene Rationale: Placing clients in positive pressure isolation rooms Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.
A client's most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding? a)The client is likely to have a decreased level of blood urea nitrogen (BUN). b) The client is likely to have irregular voiding patterns. c) The client is likely to have increased serum creatinine levels. d) The client is at risk for hypokalemia.
C) The client is likely to have increased serum creatinine levels. Rationale: The adult GFR can vary from a normal of approximately 125 mL/min (1.67 to 2.0 mL/sec) to a high of 200 mL/min. A low GFR is associated with increased levels of BUN, creatinine, and potassium.
. A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has what type of immune disorder? a) A primary immune deficiency b) A rheumatic disorder c) An autoimmune disorder d) A gammopathy
C) an autoimmune disorder Rationale: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function.
A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? SELECT ALL THAT APPLY. a) Administering insulin to reduce blood glucose levels b) Administering diuretics to prevent fluid overload c) Applying interventions to reduce the client's temperature d) Administering corticosteroids e) Administering beta-blockers to reduce heart rate
C) applying interventions to reduce the client's temperature E) administering beta-blockers to reduce heart rate Rationale: Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? a) Having the client frequently rate his or her hunger on a 10-point scale b) Measuring the client's heart rhythm at least every 6 hours c) Checking the client's capillary blood glucose levels regularly d) Monitoring the client's level of consciousness each shift
C) checking the client's capillary blood glucose levels regularly Rationale: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.
The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider to use to drain the client's bladder? a) medication administration to relax the bladder muscles and reattempting catheterization in 6 hours b) scheduling the client immediately c) insertion of a suprapubic catheter d) application of warm compress to the perineum to assist with relaxation
C) insertion of a suprapubic catheter Rationale: When the client cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm.
A client is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The client is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response? a) Obtain a sterile urine sample and send it for culture. b) Report this finding promptly to the primary provider. c) Reassure the client that this is an expected phenomenon. d) Obtain a urine sample and check it for pH.
C) reassure the client that this is an expected phenomenon Rationale: Because mucous membrane is used in forming the conduit, the client may excrete a large amount of mucus mixed with urine. This causes anxiety in many clients. To help relieve this anxiety, the nurse reassures the client that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required.
A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client's abdomen is increasing in girth. What is the nurse's most appropriate action? a) Advance the catheter 2 to 4 cm further into the peritoneal cavity. b) Infuse 50 mL of additional dialysate. c) Reposition the client to facilitate drainage. d) Aspirate from the catheter using a 60-mL syringe.
C) reposition the client to facilitate drainage Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate.
The nurse on a urology unit is working with a client who has been diagnosed with oxalate renal calculi. When planning this client's health education, what nutritional guidelines should the nurse provide? a) Increase intake of potassium-rich foods. - b)Encourage intake of food containing oxalates. c) Restrict protein intake as prescribed. d) Follow a low-calcium diet.
C) restrict protein intake as prescribed Rationale: Protein is restricted to 60 g/day, while sodium is restricted to 3 to 4 g/day. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The client should avoid intake of oxalate-containing foods and there is no need to increase potassium intake
A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedure care? a) Administer a bolus of 500 mL normal saline following the procedure b) Insert a urinary catheter for 24 to 48 hours after the procedure c) Strain the client's urine following the procedure d) Monitor the client for fluid overload following the procedure
C) strain the client's urine following the procedure Rationale: Following ESWL, the nurse should strain the client's urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.
A client who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the client? a) Remind the client that occasional febrile episodes are expected following ESWL. b) Remind the client that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. c) Tell the client to report to the ED for further assessment. d) Tell the client to monitor his temperature for the next 24 hours and then contact his urologist's office.
C) tell the client to report the ED for further assessment Rationale: Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.
. A client is in the primary infection stage of HIV. What is true of this client's current health status? a) The client's risk for opportunistic infections is at its peak. b) The client's HIV antibodies are successfully, but temporarily, killing the virus. c) The client is infected with HIV but lacks HIV-specific antibodies. d) The client may or may not develop long-standing HIV infection.
C) the client is infected with HIV but lacks HIV -specific antibodies Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.
The nurse is caring for a client who describes changes in his voiding patterns. The client states, "I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesn't seem to be much urine flow." What would the nurse expect this client's physical assessment to reveal? a) Kidney injury b) Hematuria c) Urine retention d) Dehydration
C) urine retention Rationale: Increased urinary urgency and frequency coupled with decreasing urine volumes strongly suggest urine retention. Hematuria may be an accompanying symptom, but is likely related to a urinary tract infection secondary to the retention of urine. Dehydration and kidney injury both result in a decrease in urine output, but the client with these conditions does not have normal urine production and decreased or minimal flow of urine to the bladder. The symptoms of urgency and frequency do not accompany kidney injury and dehydration due to decreased urine production.
A 76-year-old client with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? a) "I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare." b) "The decision is certainly yours to make, but be sure not to make a mistake." c) "Have you talked this over with your family?" d) "Kidney transplants in clients your age are as successful as they are in younger clients."
D) "Kidney transplants in clients your age are as successful as they are in younger clients." Rationale: Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the elderly. However, the outcome is comparable to that of younger clients. The other listed options either belittle the client or give the client misinformation.
The nurse caring for a client with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? a) Administration of dexamethasone IV, followed by an x-ray of the adrenal glands b) Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is given c) Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours d) Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning
D) - Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning Rationale: Dexamethasone (1 mg) is given orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning. This test can be performed on an outpatient basis and is the most widely used and sensitive screening test for diagnosis of pituitary and adrenal causes of Cushing syndrome.
The nurse is reviewing the electronic health record of a client with a history of incontinence. The nurse reads that the health care provider assessed the client's deep tendon reflexes. What condition of the urinary/renal system does this assessment address? a) Recurrent urinary tract infections (UTIs) b) Bengin prostatic hyperplasia (BPH) c) Renal calculi d) Bladder dysfunction
D) bladder dysfunction Rationale: The deep tendon reflexes of the knee are examined for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction, because the sacral area, which innervates the lower extremities, is in the same peripheral nerve area responsible for urinary continence. Neurologic function does not directly influence the course of renal calculi, BPH, or UTIs.
. A client who has AIDS has been admitted for the treatment of Kaposi sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS? a) Risk for Disuse Syndrome Related to Kaposi Sarcoma b) Diarrhea Related to Kaposi Sarcoma c) Impaired Swallowing Related to Kaposi Sarcoma d) Impaired Skin Integrity Related to Kaposi Sarcoma
D) imapired skin integrity related to Kaposi Sarcoma Rationale: Kaposi sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.
A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy? a) Anemia b) Agranulocytosis c) Thrombocytopenia d) Immunosuppression
D) immunosupression Rationale: Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.
A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this client are what? a) 5% deficit in body weight compared to preillness weight and increased caloric need b) Calorie deficit and muscle wasting combined with low electrolyte levels c) Significant risk of aspiration coupled with decreased level of consciousness d) Inability to take in adequate oral food or fluids within 7 days
D) inability to take in adequate oral food or fluids within 7 days Rationale: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral.
A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventative measure should the nurse encourage the client to adopt? a) Adopting a high-calcium diet b) Eating several small meals each day c) Increasing intake of protein from plant sources d) Increasing fluid intake
D) increasing fluid intake Rationale: Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein intake from all sources should be limited. Most clients do not require a low-calcium diet, but increased calcium intake would be contraindicated for all clients. Eating small, frequent meals does not influence the risk for recurrence.
A client with a recent history of nephrolithiasis has presented to the ED. After determining that the client's cardiopulmonary status is stable, what aspect of care should the nurse prioritize? a) Insertion of an indwelling urinary catheter b) IV fluid administration c) Assisting with aspiration of the stone d) Pain management
D) pain management Rationale: The client with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the client's need for IV fluids or for catheterization. Kidney stones cannot be aspirated.
. The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? a) Risk for Ineffective Role Performance Related to Dermatitis b) Risk for Self-Care Deficit Related to Skin Lesions c) Risk for Disuse Syndrome Related to Dermatitis d) Risk for Disturbed Body Image Related to Skin Lesions
D) risk for disturbed body image related to skin lesions Rationale: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.
A 21-year-old male has just been diagnosed with a spondyloarthropathy. What nursing intervention should the nurse prioritize? a) Referral for assistive devices b) Setting up an exercise program c) Referral to classes to stop smoking d) Teaching about symptom management
D) teaching about symptom management Rationale: Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking cessation, and exercise programs, though these topics may be of importance for some clients.
The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity? a) The client had a pulmonary embolism 18 months ago. b) The client has a family history of breast cancer. c) The client takes a beta-blocker for the treatment of hypertension. d) The client is under significant psychosocial stress.
D) the client is under significant psychosocial stress Rationale: Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta-blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represent an immediate threat to immune function.
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? a) The need for the child to avoid all foods that have a high potential for allergies b) The need to begin immunotherapy as soon as possible c) The need to vigilantly maintain the child's immunization status d) The need for the parents to carry an epinephrine pen
D) the needs for the parents to carry an epinephrine pen Rationale: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies.
A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. This physiologic state is known as what? a) window period b) Latent stage c) Static stage d) Viral set point
D) viral set point Rationale: The remaining amount of virus in the body after primary infection is referred to as the viral set point which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though they are infected
