202 Exam 4

The nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority? A. nutrition patterns B. personal hygiene practices C. physical functioning D. somatic complaints

A

The nurse is assessing a client who is diagnosed with borderline personality disorder. which client statement indicates the client is at risk for self-injurious behavior? a. i have felt so down lately. I dont enjoy doing anything anymore b. i do what i do because others tell me to do so c. when i feel extremely anxious, it is like my mind goes somewhere else d. it is almost as if as soon as i think of doing something, I immediately do it

A

The nurse is caring for a client diagnosed with BPD. the nurse has instructed the client about using the communication triad. The nurse determine that the client has understood this technique when he states which of the following? A. I should start by stating my feelings as an "I" statement B. maybe i should start by describing the situation that has me upset C. I should first tell the other person what I'd like to be different about the situation D. I should begin by telling the other person what has triggered my emotion

A

a women with borderline personality disorder has been admitted to the inpatient unit because she has been engaging in wrist cutting. the clients sister is visiting and the sister asks the nurse to explain why her sister sometimes does this to herself. which response would be most appropriate ? A. sometimes the self injurious behavior is undertaken to relieve stress B. self injurious behavior often calms and sedates people with this diagnosis C. sometimes they do it to avoid onslaught of delusional thinking D. the self mutilation often slows the mood swings your sister experiences

A

10. The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which response by the nurse would be most appropriate? A) "Let's put you in touch with some other girls who are also having the same body changes." B) "Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it." C) "Your real friends do not care about your appearance and just want you to get well." D) "You are beautiful in your own way; what matters is what is on the inside."

A) "Let's put you in touch with some other girls who are also having the same body changes."

6. The nurse is caring for a 4-year-old girl with vulvovaginitis. After explaining to the girl's mother how to help prevent subsequent episodes, which statement by the mother indicates a need for additional teaching? A) "She needs to wipe from front to back." B) "I will make sure she changes her underwear every day." C) "She should probably avoid bubble baths." D) "I will help supervise her wiping after bowel movements."

A) "She needs to wipe from front to back."

1. The nurse is caring for a child who is experiencing an acute renal transplant rejection and is to receive muromonab-CD3. Which of the following would the nurse most likely expect to assess after the first dose is administered? A) Fever with chills, chest tightness B) Cough, hyperkalemia C) Photosensitivity, gastrointestinal (GI) upset D) Urinary retention, decreased appetite

A) Fever with chills, chest tightness

17. A 15-year-old boy comes to the emergency department accompanied by his parents. The boy reports an abrupt onset of sudden pain on the right side of his scrotum. When asked to rate his pain on a scale of 1 to 10, with 10 being the most severe, the boy states, "It's a 12." Further assessment reveals a blue-black swelling on the affected side. The nurse suspects testicular torsion and immediately notifies the physician based on the understanding of which of the following? A) The condition is a surgical emergency. B) The boy is at risk for sepsis C) Intravenous antibiotics need to be initiated. D) Renal failure is imminent.

A) The condition is a surgical emergency.

26. A child returns from surgery in which a stoma was created in the abdominal wall to the bladder. The nurse identifies this as which of the following? A) Vesicostomy B) Ureteral stent C) Continent urinary diversion D) Bladder augmentation

A) Vesicostomy

15) The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula? A) A vein and an artery in your arm will be attached surgically. B) The arm should be immobilized for 4 to 6 days. C) One needle will be inserted into the fistula for each dialysis treatment. D) The fistula can be used 2 days after the surgery for dialysis treatment.

A) A vein and an artery in your arm will be attached surgically. The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need time, usually 2 to 3 months, to mature before it can be used. The patient is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.

4. A nurse is reading a journal article about the various theories associated with the development of antisocial personality disorder. The article mentions difficult temperament as a possible theory. The nurse demonstrates understanding of this concept when identifying which of the following as a key behavior associated with a difficult temperament? Select all that apply. A) Aggression B) Inattention C) Hyperactivity D) Impulsivity E) Depression F) Paranoia

A) Aggression B) Inattention C) Hyperactivity D) Impulsivity

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? A) An insect bite B) Dehydration C) Sunburn D) Excessive perspiration

A) An insect bite The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

1. The nurse is preparing to assess a client with a paranoid personality trait. The nurse integrates knowledge of this condition, anticipating that the client's affect and behavior will most likely be which of the following? A) Angry and hostile B) Flirtatious and seductive C) Fearful and anxious D) Friendly and open

A) Angry and hostile

An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many spots on her skin. What would be an appropriate response by the nurse? A) As people age, they normally develop uneven pigmentation in their skin. B) These spots are called liver spots or age spots. C) Older skin is more apt to break down and tear, causing sores. D) These are usually the result of nutritional deficits earlier in life.

A) As people age, they normally develop uneven pigmentation in their skin. The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults vulnerability to skin damage do not answer the sons question. These lesions are not normally a result of nutritional imbalances.

10) The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A) Assessment of the quantity of the patients urine output B) Assessment of the patients incision C) Assessment of the patients abdominal girth D) Assessment for flank or abdominal pain

A) Assessment of the quantity of the patients urine output After kidney transplantation, the nurse should perform all of the listed assessments. However, oliguria is considered to be more suggestive of rejection than changes to the patients abdomen or incision.

An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patients face is a cherry-red color. What should the nurse suspect? A) Carbon monoxide poisoning B) Anemia C) Jaundice D) Uremia

A) Carbon monoxide poisoning Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark-skinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin.

A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions? A) Cataract development is possible. B) The ointment is likely to cause weeping. C) Corticosteroid use is contraindicated on these lesions. D) The patient may develop glaucoma.

A) Cataract development is possible.

The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what? A) Cherry angiomas B) Solar lentigo C) Seborrheickeratoses D) Xanthelasma

A) Cherry angiomas Cherry angiomas appear as bright red moles, while solar lentigo are commonly called liver spots. Seborrheickeratoses are described as crusty brown stuck on patches, while xanthelasma appears as yellowish, waxy deposits on the upper eyelids.

16) A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply. A) Decreased protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction E) Vitamin D supplementation

A) Decreased protein intake B) Decreased sodium intake D) Fluid restriction Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium intake is usually limited, not increased, and there is no particular need for vitamin D supplementation.

A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include? A) Deficient Knowledge about Early Signs of Melanoma B) Chronic Pain Related to Surgical Excision and Grafting C) Depression Related to Reconstructive Surgery D) Anxiety Related to Lack of Social Support

A) Deficient Knowledge about Early Signs of Melanoma

5. A nurse is developing a plan of care for a client diagnosed with an antisocial personality disorder who has been admitted to the inpatient psychiatric unit. Which of the following would the nurse most likely include? Select all that apply. A) Developing a therapeutic relationship B) Bargaining about the unit rules C) Holding the client responsible for behavior D) Discouraging client from discussing thoughts E) Using a firm, lecture-like approach for teaching

A) Developing a therapeutic relationship C) Holding the client responsible for behavior

A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate? A) Does anyone in your family have eczema or psoriasis? B) Have any of your family members been diagnosed with malignant melanoma? C) Do you have a family history of vitiligo or port-wine stains? D) Does any member of your family have a history of keloid scarring?

A) Does anyone in your family have eczema or psoriasis?

1) The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria

A) Hematuria The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Some degree of edema and hypertension is noted in most patients.

7) A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.

A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to test creatinine clearance at a later time. The laboratory does not monitor the urine for sodium or potassium concentrations.

13) A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis? A) Hemodialysis is a treatment option that is usually required three times a week. B) Hemodialysis is a program that will require you to commit to daily treatment. C) This will require you to have surgery and a catheter will need to be inserted into your abdomen. D) Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again.

A) Hemodialysis is a treatment option that is usually required three times a week. Hemodialysis is the most commonly used method of dialysis. Patients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatments usually occur three times a week for at least 3 to 4 hours per treatment.

13. A nurse is interviewing a client and suspects that the client may have narcissistic personality disorder. Which client statement would help support the nurse's suspicions? A) I have a very important position in life; everyone I know wants to be like me. B) My wife is poisoning my food so she can get rid of me and marry her boss. C) I like to work alone because then I can let my thoughts wander. D) I'm always the life of the party, making new friends all the time.

A) I have a very important position in life; everyone I know wants to be like me.

When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what? A) Impaired Skin Integrity Related to Scaly Lesions B) Acute Pain Related to Blistering and Erosions of the Oral Cavity C) Impaired Tissue Integrity Related to Epidermal Shedding D) Anxiety Related to Risk for Melanoma

A) Impaired Skin Integrity Related to Scaly Lesions

10. A client is brought into the emergency department because of complaints from the neighbors that the client was acting strangely. The nurse assesses the client and suspects schizotypal personality disorder based on assessment of which of the following? Select all that apply. A) Magical beliefs B) Hallucinations C) Paranoia D) Avoidance of eye contact E) Meticulous dress

A) Magical beliefs C) Paranoia D) Avoidance of eye contact

32) The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? A) Maintain aseptic technique when administering dialysate. B) Wash the skin surrounding the catheter site with soap and water prior to each exchange. C) Add antibiotics to the dialysate as ordered. D) Administer prophylactic antibiotics by mouth or IV as ordered.

A) Maintain aseptic technique when administering dialysate. Aseptic technique is used to prevent peritonitis and other infectious complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection.

A patients blistering disorder has resulted in the formation of multiple lesions in the patients mouth. What intervention should be included in the patients plan of care? A) Provide chlorhexidine solution for rinsing the patients mouth. B) Avoid providing regular mouth care until the patients lesions heal. C) Liaise with the primary care provider to arrange for parenteral nutrition. D) Encourage the patient to gargle with a hypertonic solution after each meal.

A) Provide chlorhexidine solution for rinsing the patients mouth.

30) The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply. A) Providing emotional support for the family B) Monitoring for complications C) Participating in emergency treatment of fluid and electrolyte imbalances D) Providing nursing care for primary disorder (trauma) E) Directing nutritional interventions

A) Providing emotional support for the family B) Monitoring for complications C) Participating in emergency treatment of fluid and electrolyte imbalances D) Providing nursing care for primary disorder (trauma) The nurse has an important role in caring for the patient with AKI. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the patients progress and response to treatment, and provides physical and emotional support. Additionally, the nurse keeps family members informed about the patients condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract). The nurse does not direct the patients nutritional status; the dietician and the physician normally collaborate on directing the patients nutritional status.

3. A nursing instructor is preparing a teaching plan for a class of nursing students about antisocial personality disorder. Which of the following would the nurse include as a term often used to describe the behaviors associated with this condition? Select all that apply. A) Psychopath B) Manipulator C) Criminality D) Sociopath E) Psychotic

A) Psychopath D) Sociopath

37) The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply. A) Quantity of output B) Color of the output C) Visible characteristics of the output D) Odor of the output E) pH of the output

A) Quantity of output B) Color of the output C) Visible characteristics of the output Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Odor and pH are not normally assessed.

A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply. A) Risk for Infection Related to Lesions B) Impaired Skin Integrity Related to Epidermal Blisters C) Disturbed Body Image Related to Presence of Skin Lesions D) Acute Pain Related to Disruption in Skin Integrity E) Hyperthermia Related to Disruptions in Thermoregulation

A) Risk for Infection Related to Lesions B) Impaired Skin Integrity Related to Epidermal Blisters C) Disturbed Body Image Related to Presence of Skin Lesions D) Acute Pain Related to Disruption in Skin Integrity

2. The nurse is caring for a client with schizoid personality trait. When developing the plan of care for the client, which of the following would the nurse most likely include? A) Social skills training B) Anger management training C) Relaxation techniques D) Coping skills training

A) Social skills training

An older adult patient is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse? A) Spend time outdoors at least twice per week B) Increase intake of leafy green vegetables C) Start taking a multivitamin each morning D) Eat red meat at least once per week

A) Spend time outdoors at least twice per week Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). It is estimated that most people need five to thirty minutes of sun exposure twice a week in order for this synthesis to occur. Multivitamins may not resolve a specific vitamin D deficiency. Vitamin D is unrelated to meat and vegetable intake.

39) A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients 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 are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. E) The cuffs absorb dialysate

A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. 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 patient presents at the free clinic with a black, wart-like lesion on his face, stating, Ive done some research, and Im pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis? A) The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable. B) The patients lesion will be closely observed for 6 months before a plan of treatment is chosen. C) The patient has one of the few dermatologic malignancies that respond to chemotherapy. D) The patient will likely require wide excision.

A) The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable.

A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan? A) Use caution when taking nonprescription medications. B) Avoid public places until symptoms subside. C) Wash skin frequently to prevent infection. D) Liberally apply corticosteroids as needed.

A) Use caution when taking nonprescription medications.

4) The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what? A) Wash hands carefully and frequently. B) Ensure immediate function of the donated kidney. C) Instruct the patient to wear a face mask. D) Bar visitors from the patients room.

A) Wash hands carefully and frequently. The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with active infections. Careful handwashing is imperative; face masks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the patient is receiving high doses of immunosuppressants. Visitors may be limited, but are not normally barred outright. Ensuring kidney function is vital, but does not prevent infection.

A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient? A) Wash your face with water and gentle soap each morning and evening. B) Before bedtime, clean your face with rubbing alcohol on a cotton pad. C) Gently burst new pimples before they form a visible head. D) Set aside time each day to squeeze blackheads and remove the plug.

A) Wash your face with water and gentle soap each morning and evening.

A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following? A) Wrinkles near the lips and eyes B) Removal of acne scars C) Vascular lesions on the cheeks D) Real or perceived misshaping of the eyes

A) Wrinkles near the lips and eyes

A client with BPD tells the nurse, Im afraid to get on the train because well probably get into a wreck. Which response by the nurse would be most appropriate? A. Have you had a bad experience riding a train? B. what are the chances of that actually happening C. now you know that wont happen D. have you thought about going by automobile

B

A nurse is assessing a client with BPD. Which question would be most appropriate to assess the clients level of impulsivity? A. what things bother you and make you feel happy B. have you ever felt sorry after acting as you did in the spur of the moment? C. how do you view other people around you? D. have you ever felt like you were separated from your body?

B

a nurse is assisting a client with bpd in how to manage transient psychotic episodes that involve auditory hallucinations. the teaching is planned for times when the client is free of these symptoms. which of the following would the nurse instruct the client to do first? A. use skills to tolerate painful feelings B. practice deep abdominal breathing C. identify early internal cues of distress D. refer to cards listing potential symptoms

B

25. While presenting a panel discussion to a group of parents about urinary tract infections in children, one of the parents asks the nurse, "Why would my daughter be more at risk than my son?" Which response by the nurse would be most accurate? A) "Girls have a smaller bladder size than boys do." B) "A girl's urethra is closer to the rectal opening." C) "A girl's urethra is longer than a boy's urethra." D) "Her kidneys are less well protected."

B) "A girl's urethra is closer to the rectal opening."

9. The nurse is taking a health history of a child with suspected acute poststreptococcal glomerulonephritis. Which of the following responses would alert the nurse to a confirmed risk factor for this condition? A) "She has been very healthy up to now." B) "He just got over a head cold with laryngitis." C) "My child is just 18 months old." D) "My child has not been sick at all."

B) "He just got over a head cold with laryngitis."

3. The nurse is caring for a 4-year-old with a suspected urinary tract infection. Which of the following would be most appropriate when obtaining a urine specimen from the child? A) "I will need a urine sample." B) "Let your mom help you tinkle in this cup." C) "Please tinkle in this cup right now." D) "Please void in this cup instead of the toilet."

B) "Let your mom help you tinkle in this cup."

2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The nurse documents gross hematuria with a specimen of which color? A) Cloudy yellow B) Cola colored C) Pale to almost clear urine D) Light orange to moderately yellow colored

B) Cola colored

14. A child is diagnosed with hemolytic-uremic syndrome (HUS). Review of the child's laboratory test results would reveal which of the following? A) Decreased blood urea nitrogen (BUN) and creatinine B) Decreased platelets and leukocytosis C) Hypernatremia and hypokalemia D) Respiratory acidosis and proteinuria

B) Decreased platelets and leukocytosis

16. A nurse is conducting a physical examination of an infant and observes the urethral opening on the dorsal side of the penis. The nurse documents this finding as which of the following? A) Hypospadias B) Epispadias C) Varicocele D) Hydrocele

B) Epispadias

21. A nurse is preparing a presentation for a local parent group about urinary tract infections (UTIs) in children. Which of the following would the nurse incorporate into the presentation as the most common cause? A) Klebsiella B) Escherichia coli C) Staphylococcus aureus D) Pseudomonas

B) Escherichia coli

28. The nurse is assessing a 5-year-old child's genitourinary system. Which of the following would the nurse document as a normal finding? Select all answers that apply. A) Labial fusion B) Round abdomen C) Positive bowel sounds D) Dullness over the spleen E) Undescended testicles

B) Round abdomen C) Positive bowel sounds D) Dullness over the spleen

9) The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease

B) A patient with diabetes mellitus and poorly controlled hypertension Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents may cause ESKD. A patient with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the patient with diabetes and hypertension is likely at highest risk for ESKD.

34) The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician? A) Increased pain on movement B) Absence of drain output C) Increased urine output D) Blood-tinged serosanguineous drain output

B) Absence of drain output Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage is promptly reported to the physician because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines. Reporting increased pain on movement has nothing to do with the scenario described. Increased urine output and serosanguineous drainage are expected.

A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash? A) Is the rash worse at a particular time or season? B) Are you allergic to any foods or medication? C) Are you having any loss of sensation in that area? D) Is your rash painful?

B) Are you allergic to any foods or medication? The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the patients immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

19) The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. A) Percuss for pain in the right lower abdominal quadrant. B) Assess for the presence of peripheral edema. C) Auscultate the patients apical heart rate for dysrhythmias. D) Assess the patients BP. E) Assess the patients orientation and judgment.

B) Assess for the presence of peripheral edema. D) Assess the patients BP. Most patients with acute glomerular inflammation have some degree of edema and hypertension. Dysrhythmias, RLQ pain, and changes in mental status are not among the most common manifestations of acute glomerular inflammation.

A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next? A) Obtain a swab for culture. B) Assess the characteristics of the lesion. C) Obtain a swab for pH testing. D) Apply a test dose of broad-spectrum topical antibiotic.

B) Assess the characteristics of the lesion. If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empiric basis.

A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? A) Acyclovir (Zovirax) B) Benzoyl peroxide and erythromycin (Benzamycin) C) Diphenhydramine (Benadryl) D) Triamcinolone (Kenalog)

B) Benzoyl peroxide and erythromycin (Benzamycin)

6. A nurse is working with the family of a client who has been diagnosed with antisocial personality disorder. Which of the following would be most important for the nurse to focus on when teaching the family about this disorder? A) Anger management B) Boundary setting C) Medication therapy D) Self-responsibility

B) Boundary setting

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A) By avoiding the use of moisturizing lotions on older adults skin B) By protecting older adults against shearing injuries C) By avoiding the use of ice packs to treat muscle pain D) By protecting older adults against excessive sweat accumulation

B) By protecting older adults against shearing injuries Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults skin. Ice packs can be used, provided skin is assessed regularly and the patient possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? A) Telangiectasias B) Ecchymoses C) Purpura D) Urticaria

B) Ecchymoses Telangiectasias consists of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticariais wheals or hives.

A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient? A) Ulcer B) Ecchymosis C) Scar D) Erosion

B) Ecchymosis Ecchymosis refers to a round or irregular macular lesion, which is larger than petechiae. This occurs secondary to blood extravasation. It is important to watch for ecchymosis in a patient receiving any type of anticoagulant. An ulcer is an open lesion eroded into the patients flesh. A scar is an area on the skin caused by the healing of an injury. Erosion is loss of superficial epidermis that does not extend to the dermisa depressed, moist area.

When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply. A) Possible malignancy B) Epidermal necrosis C) Neurologic involvement D) Increased metabolic needs E) Possible gastrointestinal mucosal sloughing

B) Epidermal necrosis D) Increased metabolic needs E) Possible gastrointestinal mucosal sloughing

23) A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? A) Imbalanced nutrition: More than body requirements B) Excess fluid volume C) Sedentary lifestyle D) Adult failure to thrive

B) Excess fluid volume If the patient with AKI gains or does not lose weight, fluid retention should be suspected. Short-term weight gain is not associated with excessive caloric intake or a sedentary lifestyle. Failure to thrive is not associated with weight gain.

16. A nurse is working with a client who is a compulsive gambler. Which of the following would the nurse emphasize as crucial for relapse prevention? Select all that apply A) Medication therapy B) Family involvement C) Identification of triggers D) Anger management E) Milieu management

B) Family involvement C) Identification of triggers

A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what? A) Skin graft B) Laser treatment C) Chemical face peeling D) Free flap

B) Laser treatment

28) A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient? A) Increasing oral intake B) Managing postoperative pain C) Managing dialysis D) Increasing mobility

B) Managing postoperative pain The patient requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. Increasing oral intake and mobility are not priority nursing actions in the immediate postoperative care of this patient. Dialysis is not necessary following kidney surgery.

A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction? A) Weak positive B) Moderately positive C) Strong positive D) Severely positive

B) Moderately positive The development of redness, fine elevations, or itching is considered a weak positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction.

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? A) The childs scalp should be monitored for 48 to 72 hours before starting treatment. B) Nits may have to be manually removed from the childs hair shafts. C) The disease is self-limiting and symptoms will abate within 1 week. D) Efforts should be made to improve the childs level of hygiene.

B) Nits may have to be manually removed from the childs hair shafts.

18) A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders? A) Monitor the patients electrolyte values every hour before the procedure. B) Preprocedure hydration and administration of acetylcysteine C) Hemodialysis immediately prior to the CT scan D) Obtain a creatinine clearance by collecting a 24-hour urine specimen.

B) Preprocedure hydration and administration of acetylcysteine Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL identify the patient as being high risk. Preprocedure hydration and prescription of acetylcysteine (Mucomyst) the day prior to the test is effective in prevention. The nurse would not monitor the patients electrolytes every hour preprocedure. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast.

17) A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response? A) Assess the patient for further signs or symptoms of rejection. B) Recognize this as an expected finding. C) Inform the primary care provider of this finding. D) Administer exogenous antidiuretic hormone as ordered.

B) Recognize this as an expected finding. A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large quantities of dilute urine. This is not suggestive of rejection and treatment is not warranted. There is no obvious need to report this finding.

40) A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action? A) Advance the catheter 2 to 4 cm further into the peritoneal cavity. B) Reposition the patient to facilitate drainage. C) Aspirate from the catheter using a 60-mL syringe. D) Infuse 50 mL of additional dialysate.

B) Reposition the patient to facilitate drainage. If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient 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.

A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? A) Tzanck smear B) Skin biopsy C) Patch testing D) Skin scrapings

B) Skin biopsy A skin biopsy is done to rule out malignancies of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster. Patch testing is performed to identify substances to which the patient has developed an allergy. Skin scrapings are done for suspected fungal infections.

A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? A) Dermis B) Subcutaneous tissue C) Epidermis D) Stratum corneum

B) Subcutaneous tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones. The dermis is the largest portion of the skin, providing strength and structure. The epidermis is the outermost layer of stratified epithelial cells and composed of keratinocytes. The stratum corneum is the outermost layer of the epidermis, which provides a barrier to prevent epidermal water loss.

A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform? A) Teach the patient about early signs of secondary blistering diseases. B) Teach the patient about self-care after treatment. C) Assess the patients risk for recurrent malignancy. D) Assess the patient for adverse effects of radiotherapy.

B) Teach the patient about self-care after treatment.

14. A nurse is developing a teaching plan for a client with an impulse-control disorder. The nurse is planning to explain the emotional aspects associated with the behavior as part of the plan. Which of the following would the nurse describe as occurring first before the individual commits the act? A) Remorse B) Tension C) Regret D) Pleasure

B) Tension

7. A group of nursing students is reviewing information about antisocial personality disorder. The students demonstrate understanding of this disorder when they state which of the following? A) The disorder occurs more frequently in women. B) The individual must be at least 18 years of age. C) The disorder is found primarily in Asian individuals. D) Alcohol abuse disorder rarely accompanies this disorder.

B) The individual must be at least 18 years of age.

25) A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient? A) The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life. B) The patients disease is incurable and the nurses interventions will be supportive. C) The patient will eventually require surgical removal of his or her renal cysts. D) The patient is likely to respond favorably to lithotripsy treatment of the cysts.

B) The patients disease is incurable and the nurses interventions will be supportive. PKD is incurable and care focuses on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy.

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? A) E B) D C) A D) C

B) Vitamin D Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

A client with BPD has difficulty maintaining boundaries of the professional relationship. which of the following would be most effective for the nurse to do? select all that apply A. punish the client with seclusion for violating established boundaries B. respond to the clients arrogance in a neutral, non confrontational manner C. discuss the purpose of the limits in the therapeutic relationship D. state the parameters of limits and boundaries clearly E. ensure that any established limits are maintained consistently

B,C,D,E

The nurse has explained the biologic theories of causation to a client diagnosed with BPD and his family. the nurse determines the client and the family have understood the instructions when they state which of the following? A. the disorder may be caused by increased serotonin activity B. the disorder is caused by decreased dopamine activity in my brain C. a frontal lobe dysfunction may be causing this condition D. A decrease in hormonal substances increases the risk for this illness

C

22. A nurse is interviewing the parents of a child diagnosed with obstructive uropathy. Which statement by the parents would the nurse identify as significant? A) "She's been constipated quite a few times." B) "We've noticed that her bed is wet in the morning." C) "She had surgery to repair a problem with her anus." D) "She had a bacterial skin infection about a week ago."

C) "She had surgery to repair a problem with her anus."

24. A nurse identifies a nursing diagnosis of impaired urinary elimination related to urinary tract infection. When developing the plan of care, which of the following would be most important for the nurse to do first? A) Develop a schedule for bladder emptying B) Encourage fluid intake C) Assess usual voiding patterns D) Monitor intake and output

C) Assess usual voiding patterns

18. The nurse is reviewing the laboratory test results of a child with nephrotic syndrome. Which of the following would the nurse least likely expect to find? A) Hyperlipidemia B) Hypoalbuminemia C) Decreased blood urea nitrogen (BUN) D) Hypoproteinemia

C) Decreased blood urea nitrogen (BUN)

19. The nurse is applying a urine bag to a 15-month-old boy to collect a urine specimen. Which of the following would the nurse do first? A) Apply benzoin to the scrotal area B) Tuck the bag downward inside the diaper C) Pat the perineal area dry after cleaning D) Apply the narrow portion of the bag on the perineal space

C) Pat the perineal area dry after cleaning

8. A 6-year-old child has undergone a renal transplant and is receiving cyclosporine. The nurse instructs the parents to be especially alert for which of the following? A) Weight loss B) Hypotension C) Signs of infection D) Hair loss

C) Signs of infection

13. The mother of a child with end-stage renal disease asks the nurse why her son is getting an injection of erythropoietin. When responding to the mother, the nurse incorporates understanding of which of the following as the rationale? A) To treat low calcium levels B) To stimulate growth in stature C) To stimulate red blood cell growth D) To correct acidosis

C) To stimulate red blood cell growth

A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected? A) The largest area of the body without hair is selected. B) Any area that is not normally visible can be used. C) An area matching the color and texture of the skin at the surgical site is selected. D) An area matching the sensory capability of the skin at the surgical site is selected.

C) An area matching the color and texture of the skin at the surgical site is selected.

A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions? A) After washing, wipe lesions with sterile gauze to remove cellular debris. B) Apply antibiotic ointment to lesions after washing. C) Apply cornstarch to the patients skin after bathing to facilitate mobility. D) Avoid using water to cleanse the patients skin in order to maintain skin integrity.

C) Apply cornstarch to the patients skin after bathing to facilitate mobility.

A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? A) Assessment of the patients stool for evidence of intestinal sloughing B) Assessment of the patients apical heart rate for dysrhythmias C) Assessment of the patients joints for pain and decreased range of motion D) Assessment for cognitive changes resulting from neurologic lesions

C) Assessment of the patients joints for pain and decreased range of motion

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this residents plan of care? A) Avoid the application of skin emollients. B) Apply antibiotic ointment as ordered following baths. C) Avoid using hot water during the patients baths. D) Administer acetaminophen 4 times daily as ordered.

C) Avoid using hot water during the patients baths.

20) A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate? A) Hemodialysis B) Peritoneal dialysis C) Continuous venovenous hemodialysis (CVVHD) D) Plasmapheresis

C) Continuous venovenous hemodialysis (CVVHD) CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable patient. Peritoneal dialysis is not the best choice, as the patient may have sustained abdominal injuries during the accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance.

A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue? A) Decreased resistance to ultraviolet radiation B) Increased vulnerability to infection C) Diminished protection of tissues and organs D) Increased risk of skin malignancies

C) Diminished protection of tissues and organs Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

A patient has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this patients care, the nurse should include which of the following nursing diagnoses? A) Risk for Deficient Fluid Volume Related to Excess Sebum Synthesis B) Ineffective Thermoregulation Related to Occlusion of Sebaceous Glands C) Disturbed Body Image Related to Excess Sebum Production D) Ineffective Tissue Perfusion Related to Occlusion of Sebaceous Glands

C) Disturbed Body Image Related to Excess Sebum Production

The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time? A) Is anyone in your family allergic to anything? B) How long have you had this abrasion? C) Do you take any over-the-counter drugs or herbal preparations? D) What do you do for a living?

C) Do you take any over-the-counter drugs or herbal preparations? If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use. Ascertaining a family history of allergies would not give helpful information at this time. The patients lesion is not described as an abrasion. The patients occupation may or may not be relevant; it is more important to assess for herb or drug reactions.

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal? A) Educating participants about the relationship between general health and the risk of skin cancer B) Educating participants about treatment options for skin cancer C) Educating participants about the early signs and symptoms of skin cancer D) Educating participants about the health risks associated with smoking and assisting with smoking cessation

C) Educating participants about the early signs and symptoms of skin cancer

8. A nurse is providing care to a client with antisocial personality disorder. As part of the plan of care, the client is to participate in a problem-solving group. The nurse understands that this intervention is effective based on which rationale? A) It requires the client to develop attachments. B) It sets up specific boundaries for the client. C) It helps reinforce self-responsibility. D) It avoids confrontation about dysfunctional patterns.

C) It helps reinforce self-responsibility.

38) The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? A) Oral intake B) Pain intensity C) Level of consciousness D) Radiation of pain

C) Level of consciousness Bleeding is a major complication of kidney surgery. If undetected and untreated, this can result in hypovolemia and hemorrhagic shock. The nurses role is to observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Bleeding is not normally evidenced by changes in pain or oral intake.

A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. A) Palpation of the patients scalp B) Palpation of the patients upper extremities C) Palpation of a rash on the patients trunk D) Palpation of a lesion on the patients upper back E) Palpation of the patients fingers

C) Palpation of a rash on the patients trunk D) Palpation of a lesion on the patients upper back oves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a patients scalp, extremities, or fingers unless contact with body fluids is reasonably foreseeable.

A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen? A) Skin scrapings B) Skin biopsy C) Patch testing D) Tzanck smear

C) Patch testing Patch testing is performed to identify substances to which the patient has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.

A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A) Assess the drainage in the dressing. B) Slowly remove the soiled dressing. C) Perform hand hygiene. D) Don non-latex gloves.

C) Perform hand hygiene.

A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor? A) Recent heavy ultraviolet exposure B) Substandard hygienic conditions C) Recent administration of new medications D) Recent varicella infection

C) Recent administration of new medications

26) The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma? A) Avoiding heavy alcohol use B) Control of sodium intake C) Smoking cessation D) Adherence to recommended immunization schedules

C) Smoking cessation Tobacco use is a significant risk factor for renal cancer, surpassing the significance of high alcohol and sodium intake. Immunizations do not address an individuals risk of renal cancer.

6) A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3 Stages of chronic renal failure are based on the GFR. Stage 3 is defined by a GFR in the range of 30 to 59 mL/min/1.73 m2. This is considered a moderate decrease in GFR.

A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? A) Chemotherapy B) Radiation therapy C) Surgical excision D) Biopsy of sample tissue

C) Surgical excision

5) The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A) Using a stethoscope for auscultating the fistula is contraindicated. B) The patient feels best immediately after the dialysis treatment. C) Taking a BP reading on the affected arm can damage the fistula. D) The patient should not feel pain during initiation of dialysis.

C) Taking a BP reading on the affected arm can damage the fistula. When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, patients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.

A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this familys care? A) Ensuring that the family knows that impetigo is not contagious B) Teaching about the safe and effective use of topical corticosteroids C) Teaching about the importance of maintaining high standards of hygiene D) Ensuring that the family knows how to safely burst the childs vesicles

C) Teaching about the importance of maintaining high standards of hygiene

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)? A) Teaching participants to improve their overall health through nutrition B) Encouraging participants to identify their family history of cancer C) Teaching participants to limit their sun exposure D) Teaching participants to control exposure to environmental and occupational radiation

C) Teaching participants to limit their sun exposure

When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest? A) The scalp B) The elbows C) The palms of the hands D) The knees

C) The palms of the hands The epidermis is the thickest over the palms of the hands and the soles of the feet.

2) The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? A) The patient is complains of an inability to initiate voiding. B) The patients urine is cloudy with a foul odor. C) The patients average urine output has been 10 mL/hr for several hours. D) The patient complains of acute flank pain.

C) The patients average urine output has been 10 mL/hr for several hours. Oliguria (<500 mL/d of urine) is the most common clinical situation seen in AKI. Flank pain and inability to initiate voiding are not characteristic of AKI. Cloudy, foul-smelling urine is suggestive of a urinary tract infection.

36) A patient 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) Ensure that the patient moves the extremity with the vascular access site as little as possible. B) Change the dressing over the vascular access site at least every 12 hours. C) Utilize the vascular access site for infusion of IV fluids. D) Assess for a thrill or bruit over the vascular access site each shift.

D) Assess for a thrill or bruit over the vascular access site each shift. The bruit, or thrill, over the venous access site must be evaluated at least every shift. Frequent dressing changes are unnecessary and the patient does not normally need to immobilize the site. The site must not be used for purposes other than dialysis.

21) A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic? A) Typical diet B) Allergy status C) Psychosocial stressors D) Current medication use

D) Current medication use The kidneys are susceptible to the adverse effects of medications because they are repeatedly exposed to substances in the blood. Nephrotoxic medications are a more likely cause of AKI than diet, allergies, or stress.

A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patients health history, the nurse should identify what comorbidity as increasing the patients vulnerability to skin infections? A) Chronic obstructive pulmonary disease B) Rheumatoid arthritis C) Gout D) Diabetes

D) Diabetes Patients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

A nurse is assessing a teenage patient with acne vulgaris. The patients mother states, I keep telling him that this is what happens when you eat as much chocolate as he does. What aspect of the pathophysiology of acne should inform the nurses response? A) A sudden change in patients diet may exacerbate, rather than alleviate, the patients symptoms. B) Chocolate is not among the foods that are known to cause acne. C) Elimination of chocolate from the patients diet will likely lead to resolution within several months. D) Diet is thought to play a minimal role in the development of acne.

D) Diet is thought to play a minimal role in the development of acne

A patients health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem? A) Chronic Pain B) Impaired Skin Integrity C) Impaired Tissue Integrity D) Disturbed Body Image

D) Disturbed Body Image Alopecia areata causes hair loss in smaller defined areas. As such, it is common for the patient to experience a disturbed body image. Hair loss does not cause pain and does not affect skin or tissue integrity.

A nurse is providing care for a patient who has developed Kaposis sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body? A) Connective tissue cells in diffuse locations B) Smooth muscle cells of the gastrointestinal and respiratory tract C) Neural tissue of the brain and spinal cord D) Endothelial cells lining small blood vessels

D) Endothelial cells lining small blood vessels

8) A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A) Constipation related to immobility B) Risk for injury related to altered thought processes C) Hyperthermia related to the inflammatory process D) Excess fluid volume related to generalized edema

D) Excess fluid volume related to generalized edema The major clinical manifestation of nephrotic syndrome is edema, so the appropriate nursing diagnosis is Excess fluid volume related to generalized edema. Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen.

A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster? A) Grouped vesicles occurring on lips and oral mucous membranes B) Grouped vesicles occurring on the genitalia C) Rough, fresh, or gray skin protrusions D) Grouped vesicles in linear patches along a dermatome

D) Grouped vesicles in linear patches along a dermatome

While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer? A) Basal cell carcinoma B) Squamous cell carcinoma C) Dermatofibroma D) Malignant melanoma

D) Malignant melanoma

A nurse is providing an educational presentation addressing the topic of Protecting Your Skin. When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin? A) Islets of Langerhans B) Squamous cells C) T cells D) Melanocytes

D) Melanocytes Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin. Islets of Langerhans are clusters of cells in the pancreas. Squamous cells are flat, scaly epithelial cells. T cells function in the immune response.

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply. A) Producing antibodies B) Absorbing electrolytes C) Maintaining acid-base balance D) Physically repelling pathogens E) Preventing fluid loss

D) Physically repelling pathogens E) Preventing fluid loss The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acidbase balance, or electrolyte levels.

27) The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder? A) Nephritic syndrome B) Acute glomerulonephritis C) Nephrotic syndrome D) Polycystic kidney disease (PKD)

D) Polycystic kidney disease (PKD) PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders.

A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond? A) Liaise with the physical therapist to ensure that the patient is performing exercises safely. B) Validate the patients efforts to increase blood perfusion to the graft site. C) Remind the patient that ROM exercises should be passive, not active. D) Remind the patient of the need to immobilize the graft to facilitate healing.

D) Remind the patient of the need to immobilize the graft to facilitate healing.

An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration? A) Elbows B) Lips C) Nail beds D) Sclerae

D) Sclerae Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.

24) A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection

D) Streptococcal infection Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.

While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis? A) Cyanosis B) Addisons disease C) Polycythemia D) Vitiligo

D) Vitiligo With cyanosis, nail beds are dusky. With polycythemia, the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or external tan, is associated with Addisons disease. Vitiligo is condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky white spots, often symmetric bilaterally.

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? A) Vesicle B) Macule C) Nodule D) Wheal

D) Wheal A wheal is a primary skin lesion that is elevated and has fluid contained in the dermis. An example of a wheal would be an insect bite or hives. Vesicles, macules, and nodules are not characterized by elevation and the presence of serous fluid.

3) The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time? A) Only when needed B) Daily at bedtime C) First thing in the morning D) With each meal

D) With each meal Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate-binding medications must be administered with food to be effective.

A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment? A) Chemotherapy B) Immunotherapy C) Wide excision D) Radiation therapy

C) Wide excision

7. A nurse is caring for a 7-year-old girl scheduled for an intravenous pyelogram (IVP). Which of the following would be the priority before the test? A) Checking with the parents for any allergies B) Ensuring adequate hydration C) Giving the girl an enema D) Screening her for pregnancy

A) Checking with the parents for any allergies

A patient with human immunodeficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what? A) A reduction in the patients CD4 count B) A reduction in the patients viral load C) An adverse effect of antiretroviral therapy D) Virus-induced changes in allergy status

A) A reduction in the patients CD4 count Cutaneous signs may be the first manifestation of human immunodeficiency virus (HIV), appearing in more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with low CD4 counts and may become very atypical in immunocompromised people. Viral load increases, not decreases, as the disease progresses. Antiretrovirals are not noted to cause cutaneous changes and viruses do not change an individuals allergy status.

A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply. A) Affects people predominantly in the eastern half of Africa B) Affects men more than women C) Does not affect children D) Cannot infiltrate E) Can progress to lymphadenopathic forms

A) Affects people predominantly in the eastern half of Africa B) Affects men more than women E) Can progress to lymphadenopathic forms

33) The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response? A) Assess the patient for signs of bleeding and inform the physician. B) Monitor the patients vital signs every 15 minutes for the next hour. C) Reposition the patient and reassess vital signs. D) Palpate the patients flanks for pain and inform the physician.

A) Assess the patient for signs of bleeding and inform the physician. Bleeding may be suspected when the patient experiences fatigue and when urine output is less than 30 mL/h. The physician must be made aware of this finding promptly. Palpating the patients flanks would cause intense pain that is of no benefit to assessment.

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family? A) Has she eaten any new foods today? B) Has she bathed in the past 24 hours? C) Did she go to a friends house today? D) Was she digging in the dirt today?

A) Has she eaten any new foods today? Foods can cause skin reactions, especially in children. In most cases, this is a more plausible cause of urticaria than bathing, contact with other children, or soil-borne pathogens.

12) Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? A) Heart failure B) Glomerulonephritis C) Ureterolithiasis D) Aminoglycoside toxicity

A) Heart failure By causing inadequate renal perfusion, heart failure can lead to prerenal failure. Glomerulonephritis and aminoglycoside toxicity are renal causes, and ureterolithiasis is a postrenal cause.

14) A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.

A) Inform the physician and assess the patient for signs of infection Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary care provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the physician would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.

While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what? A) Macules B) Papules C) Vesicles D) Pustules

A) Macules A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.

9. The nurse is reviewing the medical record of a client diagnosed with antisocial personality disorder. The nurse notes that the client has had numerous episodes involving irritability, aggressiveness, and impulsivity and has exhibited callousness toward others. Based on this information, which nursing diagnosis would the nurse most likely identify as a priority? A) Risk for Other-Directed Violence B) Risk for Self-Injury C) Risk for Suicide D) Risk for Self-Directed Violence

A) Risk for Other-Directed Violence

11. A nurse is assessing a client diagnosed with avoidant personality disorder. Which of the following would the nurse most likely expect to find? Select all that apply. A) Shyness B) Feelings of inadequacy C) Feelings of superiority D) Perfectionism E) Detail oriented

A) Shyness B) Feelings of inadequacy

a group of nursing students is reviewing possible risk factors for development of bpd. the student demonstrate understanding of the information when they identify which of the following as a risk factor? select all that apply A. childhood sexual abuse B. parental loss C. substance abuse D. family history E. genetics

A,B

A nursing instructor is preparing a class discussion on personality disorders and characteristics. Which term would the instructor include to differentiate personality disorders from normal personality? select all that apply A. inflexible B. short term C. pervasive D. unstable over time E. distressing

A,C,D,E

15. After teaching the parents of a child with a hydrocele about this condition, which statement indicates that the teaching was successful? A) "If this gets worse and we don't treat it, our son could become infertile." B) "This condition should gradually go away on its own." C) "The surgeon is going to operate on him immediately." D) "It's going to be difficult putting ice packs on his scrotum."

B) "This condition should gradually go away on its own."

27. The nurse is preparing an 8-year-old girl for a cystoscopy. Which instruction would be most appropriate to give to the child? A) "You need to make sure that you don't go to the bathroom before the test." B) "You might feel some burning when you go to the bathroom afterward." C) "I'm going to have to put a tube into your bladder to empty it." D) "I have to put a thick tight rubber band around your arm to get a blood specimen."

B) "You might feel some burning when you go to the bathroom afterward."

23. The nurse is assessing a child with acute poststreptococcal glomerulonephritis. Which of the following would the nurse expect to assess? Select all answers that apply. A) Irritability B) Abdominal pain C) Hypertension D) Crackles E) Polyphagia

B) Abdominal pain C) Hypertension D) Crackles

5. The nurse is caring for an infant with bladder exstrophy. As part of the infant's preoperative plan of care, the nurse monitors for abdominal skin excoriation. Which action would be most appropriate for promoting healing and preventing further skin breakdown? A) Cleaning the area well with a scented diaper wipe B) Applying a barrier/healing cream or paste on skin C) Keeping the bladder moist and covered with a sterile bag D) Covering the area with sterile gauze pads after tub baths

B) Applying a barrier/healing cream or paste on skin

12. The nurse is preparing a teaching plan for the parents of a child with a urinary tract infection (UTI). Which of the following would the nurse encourage the parents to avoid? A) Liberal fluid intake B) Caffeine C) Cranberry juice D) Cotton underwear

B) Caffeine

A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patients subsequent care? A) Teaching the patient to safely and effectively administer immunosuppressants B) Helping the patient identify and avoid the offending agent C) Teaching the patient how to maintain meticulous skin hygiene D) Helping the patient perform wound care in the home environment

B) Helping the patient identify and avoid the offending agent

17. A nursing instructor is describing depressive and negativistic personality traits to a group of nursing students. The instructor determines that the teaching was successful when the students identify which of the following as characteristic of negativistic personality traits? Select all that apply. A) Anhedonia B) Hostility C) Pessimism D) Oppositionality E) Guilt

B) Hostility D) Oppositionality E) Guilt

A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient 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) The decision is certainly yours to make, but be sure not to make a mistake. B) Kidney transplants in patients your age are as successful as they are in younger patients. C) I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare. D) Have you talked this over with your family?

B) Kidney transplants in patients your age are as successful as they are in younger patients. 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 patients. The other listed options either belittle the patient or give the patient misinformation.

A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions? A) Gently massage the graft site daily to promote perfusion. B) Protect the graft from direct sunlight and temperature extremes. C) Protect the graft site from any form of moisture for at least 12 weeks. D) Apply antibiotic ointment to the graft site and donor site daily.

B) Protect the graft from direct sunlight and temperature extremes.

15. A nurse is reading an article about a young girl who developed gastrointestinal symptoms from a hair ball because of a ritual that she engaged in. The girl would pull out hair over several hours to relieve tension and anxiety and then eat the hair. The nurse most likely is reading an article about which of the following? A) Kleptomania B) Trichotillomania C) Pyromania D) Intermittent explosive disorder

B) Trichotillomania

Assessment of a patients leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? A) Keloid B) Ulcer C) Fissure D) Erosion

B) Ulcer An ulcer is skin loss extending past the epidermis with the involvement of necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear and erosions do not extend to the dermis.

A dermatologist has asked the nurse to assist with examination of a patients skin using a Woods light. This test will allow the physician to assess for which of the following? A) The presence of minute regions of keloid scarring B) Unusual patterns of pigmentation on the patients skin C) Vascular lesions that are not visible to the naked eye D) The presence of parasites on the epidermis

B) Unusual patterns of pigmentation on the patients skin Woods light makes it possible to differentiate epidermal from dermal lesions and hypopigmented and hyperpigmented lesions from normal skin.

A nurse is engaged in role playing with a client with BPD to assist the client in learning how to communicate effectively. Which of the following would the nurse encourage the client to use. select all that apply A. me statements B. validating perceptions with others C. paraphrasing before responding D. listening passively E. compromising

B,C,E

A client diagnosed with BPD tells the nurse that she frequently spaces out. Which response by the nurse would be most appropriate? A. do you feel stressed most of the time? B. does this frighten you when it happens? C. Whats happening around you when this occurs? D. do you feel as if you are out of your body?

C

A nurse is observing a client diagnosed with BPD on the inpatient unit. Which of the following would the nurse most likely note? A. actively participating in several different groups B. openly verbalizing feelings C. participating in relationships in which the client has control D. adhering to the personal boundaries of others

C

While assessing a 25-year-old female, the nurse notes that the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. The nurse should suspect what type of health problem? A) A metabolic disorder B) A malignancy C) A hormonal imbalance D) An infectious process

C) A hormonal imbalance Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen. This is often a normal genetic variation, but if it appears along with irregular menses and weight changes, it may indicate a hormonal imbalance. This combination of irregular menses and hair distribution is inconsistent with metabolic disorders, malignancy, or infection.

22) An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply. A) Anxiety B) Low BMI C) Age-related physiologic changes D) Chronic systemic disease E) NPO status

C) Age-related physiologic changes D) Chronic systemic disease Changes in kidney function with normal aging increase the susceptibility of elderly patients to kidney dysfunction and renal failure. In addition, the presence of chronic, systemic diseases increases the risk of AKI. Low BMI and anxiety are not risk factors for acute renal disease. NPO status is not a risk, provided adequate parenteral hydration is administered.

12. A group of nursing students is reviewing information about schizoid personality trait. The students demonstrate understanding of the information when they identify which disorder as the most common comorbid disorder? A) Depression B) Substance abuse C) Avoidant personality disorder D) Anxiety

C) Avoidant personality disorder

The nurse is performing a comprehensive assessment of a patients skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? A) By examining the patient under a Woods light B) By inspecting the patients skin in direct sunlight C) By palpating the patients skin D) By performing percussion of major skin surfaces

C) By palpating the patients skin Inspection and palpation are techniques commonly used in examining the skin. A patient would only be examined under a Woods light if there were indications it could be diagnostic. The patient is examined in a well-lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin.

29) A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase? A) Hypokalemia B)Hypocalcemia C)Dehydration D)Acute flank pain

C) Dehydration The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. Excessive losses of potassium and calcium are not typical during this phase, and diuresis does not normally result in pain.

11) The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C) Hyperkalemia Hyperkalemia, a common complication of acute kidney injury, is life-threatening if immediate action is not taken to reverse it. The administration of polystyrene sulfonate reduces serum potassium levels.

A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis sarcoma? A) Classic B) AIDS-related C) Immunosuppression-related D) Endemic

C) Immunosuppression-related

35) The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan? A) The importance of increased fluid intake B) Signs and symptoms of rejection C) Inspection and care of the incision D) Techniques for preventing metastasis

C) Inspection and care of the incision The nurse teaches the patient 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 patient has minimal control on the future risk for metastasis.

A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patients fingernail surfaces are pitted. The nurse should suspect the presence of what health problem? A) Eczema B) Systemic lupus erythematosus (SLE) C) Psoriasis D) Chronic obstructive pulmonary disease (COPD)

C) Psoriasis Pitted surface of the nails is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD.

A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? A) Crust B) Keloid C) Pustule D) Ulcer

C) Pustule A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? A) Skin biopsy B) Patch test C) Tzanck smear D) Examination with a Woods light

C) Tzanck smear The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. This is not accomplished by biopsy, patch test, or Woods light.

A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster? A) Prednisone (Deltasone) B) Azanthioprine (Imuran) C) Triamcinolone (Kenalog) D) Acyclovir (Zovirax)

D) Acyclovir (Zovirax)

As a part of clients treatment plan for BPD, the client is engaged in dialectal behavior therapy. As a part of therapy, the client is learning how to control and change behavior response to events. the nurse identifies the client as learning which type of skills? A. emotion regulation skills B. mindfullness skills C. distress tolerance skills D. self-management skills

D

20. A group of students are reviewing information about renal failure in children. The students demonstrate a need for additional teaching when they identify which agent as a potential contributor to renal failure? A) Vancomycin B) Gentamicin C) Co-trimoxazole D) Amoxicillin

D) Amoxicillin

11. An 8-year-old girl is scheduled for a renal ultrasound. Which of the following would the nurse include in the plan of care when preparing the child for this test? A) Withholding food and fluids after midnight B) Checking the child for allergies to shellfish C) Ensuring the child has a full bladder D) Informing the child she should feel no discomfort

D) Informing the child she should feel no discomfort

4. The nurse is providing postsurgical care for an infant who has undergone a hypospadias repair. Which action by the nurse would be most important to help keep the area clean while maintaining proper position of the drainage tubing? A) Keeping the drainage tube taped in an upright position B) Administering antibiotics as ordered C) Administering analgesics as prescribed D) Using a double-diapering technique

D) Using a double-diapering technique

A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? A) Maintain the patient on bed rest for the first 24 hours postoperative. B) Apply distraction techniques to relieve pain. C) Provide soft or liquid diet that is high in protein to assist with healing. D) Anticipate the need for, and administer, appropriate analgesic medications.

D) Anticipate the need for, and administer, appropriate analgesic medications.

A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect? A) Stasis ulcers B) Bullous pemphigoid C) Psoriasis D) Classic Kaposis sarcoma

D) Classic Kaposis sarcoma

A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation? A) Alopecia B) Yellowish skin tone C) Patchy, bronze pigmentation D) Hirsutism

D) Hirsutism Cushing syndrome causes excessive hair growth, especially in women. Alopecia is hair loss from the scalp and other parts of the body. Jaundice causes a yellow discoloration in light-skinned patients, but this does not accompany Cushing syndrome. Patients that have Addisons disease exhibit a bronze discoloration to their skin due to increased melanin production.

An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patients course of treatment? A) Increased thickness of the subcutaneous skin layer B) Increased vascular supply to superficial skin layers C) Changes in the character and quantity of bacterial skin flora D) Increased time required for wound healing

D) Increased time required for wound healing Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patients susceptibility to heat loss is related to atrophy of what skin component? A) Epidermis B) Merkel cells C) Dermis D) Subcutaneous tissue

D) Subcutaneous tissue The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis? A) Referring the patient to a speech therapist B) Gradually adding soft foods to diet C) Administering analgesics as prescribed D) Teaching the patient how to use and care for the prosthesis

D) Teaching the patient how to use and care for the prosthesis

A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patients wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response? A) The major complication is when the patient develops chronic pain. B) The major complication is when the patient loses sensation in the flap. C) The major complication is when the pedicle tears loose and the flap dies. D) The major complication is when the blood supply fails and the tissue in the flap dies.

D) The major complication is when the blood supply fails and the tissue in the flap dies.