310: Adult Health
A client scheduled for a cholecystectomy asks what caused the gallstones to develop. Which risk factor should the nurse list when responding to this client? (Select all that apply.) a. American Indian ethnicity b. Male sex c. Family history of gallstones d. Obesity e. Hyperlipidemia
a. American Indian ethnicity c. Family history of gallstones d. Obesity e. Hyperlipidemia
A client with COPD is recovering from a myocardial infarction. Because the client is extremely weak and can not produce an effective cough, the nurse should monitor closely for: a. Atelectasis b. Pneumonia c. Respiratory acidosis d. Pulmonary embolism
a. Atelectasis
Which of the following is not a typical sign and symptom of Cushing's Syndrome? a. Hyperpigmentation of the skin b. Hirsutism c. Purplish striae d. Moon Face
a. Hyperpigmentation of the skin
Which of the following lab values would a nurse expect to be increased in a patient with Cushing's Syndrome? Select all that apply. a. Sodium b. Potassium c. Glucose d. Aldosterone e. Cortisol
a. Sodium c. Glucose d. Aldosterone e. Cortisol
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a. Vitamin K b. Potassium c. Oral bile acids d. Vitamin B
a. Vitamin K
A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed? a. "I will wear socks." b. "I will elevate my foot." c. "I will increase fluid intake." d. "I will drink a moderate amount of alcohol."
b. "I will elevate my foot."
A client who is post op day 2 after a trans-sphenoidal resection of a pituitary tumor is now presenting with very dilute urine at a rate of 300 ml/hr. Based off these findings, the nurse expects that the patient: a. Drank too much water while the nurse wasn't looking b. Developed diabetes insipidus as a result of the surgery c. Is currently going into shock d. Will be diagnosed with SIADH
b. Developed diabetes insipidus as a result of the surgery
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? a. Remove the indwelling catheter b. Titrate the NS irrigation to run faster c. Administer protamine sulfate IVP d. Administer vitamin K slowly
b. Titrate the NS irrigation to run faster
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? a. "Be sure to eat meat at every meal" b. "Drink plenty of fluids, and use a salt substitute" c. "Increase your carbohydrate intake" d. "Eat plenty of bananas"
c. "Increase your carbohydrate intake"
Which patient would a nurse determine is at heightened risk for hypothyroid? a. 35-year-old male patient who smokes a pack per day. b. 81-year-old male patient who frequently consumes seafood and dairy products c. 43-year-old female patient who is taking lithium to manage bipolar disorder. d. 55-year-old female patient with Grave's Disease
c. 43-year-old female patient who is taking lithium to manage bipolar disorder.
A nurse is admitting a client with a diagnosis of Addison's disease to the hospital. On assessment, the nurse would expect to note which finding that is a manifestation of this disorder? a. Peripheral edema b. Excessive facial hair c. Lower than normal blood glucose level d. High blood pressure
c. Lower than normal blood glucose level
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? a. Place the patient in the prone position for 30minutes/day b. Assist the patient in acutely flexing the thigh to promote movement c. Place a pillow in the axilla when there is limited external rotation d. Place patient's hands in pronation
c. Place a pillow in the axilla when there is limited external rotation
Which condition indicates an overdose of lactulose? a. Fecal impaction b. Constipation c. Watery diarrhea d. Hypoactive bowel sounds
c. Watery diarrhea
On admission assessment, a client is diagnosed with GERD. Which clinical manifestations would the nurse expect to find? a. weight loss, dysarthria, and diarrhea. b. decreased abdominal fat, proteinuria, and constipation. c. pyrosis , water brash , and flatulence d. Midepigastric pain, positive H pylori test, and melena
c. pyrosis , water brash , and flatulence
A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist? a. Gastric secretion study b. Barium study of the upper gastrointestinal tract c. Stool antigen test d. Endoscopy
d. Endoscopy
A client is being evaluated for hypothyroidism. To plan care the nurse should ask the client about which sign or symptom? a. Corneal abrasion b. Weight loss c. Diarrhea d. Fatigue
d. Fatigue
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a. Encouraging ambulation to prevent pooling of blood b. Providing warmth to the extremity c. Elevating the extremity to prevent pooling of blood d. Forcing blood into the deep venous system
d. Forcing blood into the deep venous system
A patient reports they do not eat enough iodine in their diet. What condition are they most susceptible to? a. Pheochromocytoma b. Hyperthyroidism c. Thyroid Storm d. Hypothyroidism
d. Hypothyroidism
Clinical manifestations of common bile duct obstruction include all of the following except: a. Jaundice b. Clay-colored feces c. Pruritus d. Light-colored urine
d. Light-colored urine
A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? a. BUN level of 12 mg/dl b. Blood glucose level of 90 mg/dl c. Serum sodium level of 134 mEq/L4 d. Serum potassium level of 5.8 mEq/L
d. Serum potassium level of 5.8 mEq/L
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: a. Calcium and phosphorus abnormalities b. Chloride and magnesium abnormalities c. Sodium and chloride abnormalities d. Sodium and potassium abnormalities
d. Sodium and potassium abnormalities
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? a. Encourage oral fluids b. Administer furosemide (lasix) 20mg Iv c. Start hemodialysis after a temporary access is obtained d. Start IV fluids with a normal saline solution bolus followed by a maintenance dose
d. Start IV fluids with a normal saline solution bolus followed by a maintenance dose
The nurse is caring for a patient who has had a plaster leg cast applied. Immediately post-application, the nurse should inform the patient that: a. The cast will cool in 5 minutes b. The cast should be covered with a towel c. The cast should be supported on a board while drying d. The cast will only have full strength when dry
d. The cast will only have full strength when dry
What is the main symptom experienced by patients with Conns syndrome? a. Low urine output b. High Blood pressure c. Weak pulse d. Numbness around mouth
b. High Blood pressure
An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to? a. Hyperkalemia b. Hypokalemia c. Hyponatremia d. Hypernatremia
b. Hypokalemia
The nurse is reviewing the history and physical examination of a client diagnosed with hyperthyroidism. Which of the following would the nurse expect to find? a. Complaints of sleepiness b. Reports of increased appetite c. Thick hard nails d. Inability to tolerate cold
b. Reports of increased appetite
When caring for a client with hypocalcemia, the nurse should assess for: a. A decreased level of consciousness b. Tetany c. Bradycardia d. Respiratory depression
b. Tetany
Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure? a. Urinary retention b. Activity intolerance c. Fluid volume excess d. Disturbed body image
c. Fluid volume excess
A nurse is caring for an acutely ill patient. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill patient is which of the following? a. Pulse rate b. Blood pressure c. Weight d. Edema
c. Weight
Which clinical manifestation would the nurse expect to find from damage to major blood vessels caused by a fractured tibia? a. Epigastric distress before a meal b. Nonpalpable abdominal mass c. Abdominal pain in the upper left quadrant d. Clay-colored stools
d. Clay-colored stools
Which of the following associated disorders may a client with ulcerative colitis exhibit? a. Gallstones b. Hydronephrosis c. Nephrolithiasis d. Toxic megacolon
d. Toxic megacolon
When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind? a. Duration of insulin b. Accuracy of the dosage c. Technique for injecting d. Area for insulin injection
b. Accuracy of the dosage
A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? a. Frequent urination b. An irregular apical pulse c. Pitting edema of the legs d. Dry mucous membranes
b. An irregular apical pulse
The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse , "The doctor says my tumor is benign. What does that mean?" What is the nurses best response? a. "Benign tumors don't usually cause death" b. "This means the tumor has metastasized" c. "This is an aggressive, fast spreading tumor" d. "This tumor is very small"
a. "Benign tumors don't usually cause death"
A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? a. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex."
a. "You may have eaten contaminated restaurant food."
A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply. a. Weight gain b. Dark urine c. Clay-colored stools d. Jaundice e. Persistent hiccups
b. Dark urine c. Clay-colored stools d. Jaundice
Which part of the digestive system can Crohn's patches appear? a. Stomach b. Small intestine c. Large intestine d. Esophagus e. Rectum f. All of the above
f. All of the above
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Restricting Fluids b. Administer Normal Saline at a rate of 100ml/hr c. Ambulate the patient multiple times per day to promote sweating d. Administer ordered Vasopressin
a. Restricting Fluids
A nurse is teaching a group of students about what signs/symptoms are indicative of Cushing's syndrome. What s/s should be included? select all that apply a. water retention b. Dehydration c. Moon face d. Increased hair production e. Buffalo hump f. Intolerance to cold
a. Water retention c. Moon face d. Increased hair production e. Buffalo hump
A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? a. Pyloric sphincter b. Lower esophageal sphincter c. Hypopharyngeal sphincter d. Upper esophageal sphincter.
b. Lower esophageal sphincter
Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? a. Polyuria b. Polydipsia c. Polyphagia d. Extreme thirst
c. Polyphagia
Which statements by a patient with AAA indicate that teaching has been effective? (select all that apply) a. I need to quit smoking b. I need to go to the emergency department immediately if I have new severe abdominal pain c. The Doctor may put me on blood thinners d. I need to stay on my blood pressure medication e. I should keep my legs elevated whenever possible
a. I need to quit smoking b. I need to go to the emergency department immediately if I have new severe abdominal pain d. I need to stay on my blood pressure medication
A client with a history of kidney stone formation is being discharged after surgery to remove the kidney stone. What instructions should the nurse include in the client's discharge teaching plan? a. Increase daily fluid intake to at least 2 to 3 L b. Strain urine at home regularly c. Eliminate meat products from the diet d. Follow measures to alkalinize the urine
a. Increase daily fluid intake to at least 2 to 3 L
The root cause of cancer is damage to cellular DNA which can be caused by many factors, or carcinogens. What factors can be carcinogenic? (Select all that apply) a. viruses b. age c. gender d. environmental factors e. dietary substances
a. viruses d. environmental factors e. dietary substances
A client with obesity is diagnosed with pulmonary embolism (PE). Which assessment data would the nurse expect to find? Select all that apply. a. Bradycardia b. Chest pain c. Chills and fever d. Hypoxemia e. Tachypnea f. Tracheal deviation
b. Chest pain d. Hypoxemia e. Tachypnea
The nurse is planning care for a 52-year-old male client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a. Risk for Infection b. Decreased cardiac output c. Impaired physical mobility d. Imbalanced nutrition: less than body requirement
b. Decreased cardiac output
The nurse is caring for a hospitalized client with admitting diagnosis of right-sided heart failure (HF). What assessment finding is most consistent with the client's diagnosis? a. Pulmonary edema b. Distended neck veins c. Dry hacking cough d. Orthopnea
b. Distended neck veins
When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a. Administering frequent oral feedings b. Encouraging frequent visits from family and friends c. Positioning the client on the side with knees flexed d. Administering an analgesic once per shift, as ordered, to prevent drug addiction
c. Positioning the client on the side with knees flexed
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? a. The client's peripheral edema has gone from 3+ to 4+ b. The client is able to take the radial pulse accurately c. The client is able to perform ADLs without dyspnea d. The client has minimal jugular vein distention
c. The client is able to perform ADLs without dyspnea
While preparing the patient for a chest tube insertion, the nurse should perform all of the following except: a. Make sure the patient has given informed consent b. Explain to the patient that a local anesthetic will reduce discomfort c. Reinforce the practitioner's explanation of the procedure with the patient and their family d. Express the need to keep the drainage system at chest level
d. Express the need to keep the drainage system at chest level
The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm? a. Premature ventricular contractions b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia
d. Ventricular tachycardia
The clinic nurse is caring for a 42 year old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy . Which response by the nurse would best reassure the patient? a. "These symptoms usually result from radiation therapy ; however, we will continue to monitor your laboratory and x-ray studies" b. "These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer. " c. "Try not to be concerned about these symptoms, every patient feels this way after having radiation" d. "Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying."
a. "These symptoms usually result from radiation therapy ; however, we will continue to monitor your laboratory and x-ray studies"
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a. A 70-year-old male, with high cholesterol and hypertension b. A 40-year-old female with obesity and metabolic syndrome c. A 60-year-old male with renal insufficiency who is physically inactive d. A 65-year-old female with hyperhomocysteinemia and substance abuse
a. A 70-year-old male, with high cholesterol and hypertension
1) A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. What disorder is this patient most likely experiencing? a. Addisonian Crisis b. Cushing Syndrome c. Thyroid crisis d. Hashimoto thyroiditis
a. Addisonian Crisis
1. The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? Select all that apply a. Administer analgesics at regularly scheduled intervals b. Encourage fluid intake of up to 3 L/day c. Instruct client to stay on bed rest d. Provide massage to the client's flank e. Strain all urine for the presence of stone
a. Administer analgesics at regularly scheduled intervals b. Encourage fluid intake of up to 3 L/day e. Strain all urine for the presence of stone
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? a. An elevated B-type natriuretic peptide (BNP) b. An elevated creatine kinase (CK-MB) c. A positive D-dimer d. A positive ventialtion/perfusion (V/Q) scan
a. An elevated B-type natriuretic peptide (BNP)
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? a. Begin ECG monitoring b. Obtain information about family history of heart disease c. Auscultate lung fields d. Determine if the patient smokes
a. Begin ECG monitoring
Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. a. Compromised gas exchange b. Decreased airflow c. Wheezes d. JVD e. Ascites
a. Compromised gas exchange b. Decreased airflow c. Wheezes
Which clinical manifestations would a nurse expect to see in a client with Conn's syndrome? Select all that apply. a. Decreased potassium b. Increased aldosterone c. Decreased sodium d. Decreased serum renin
a. Decreased potassium b. Increased aldosterone d. Decreased serum renin
As the Nurse Caring for patient on a cardiac monitor, you understand which of the following steps are necessary to correctly identify the rhythm (select all that apply) a. Determine the rate b. Determine the regularity c. Determine if there is a P wave for every QRS d. Determine if there is a QRS for every P wave e. Determine if there is a U wave for every QRS
a. Determine the rate b. Determine the regularity c. Determine if there is a P wave for every QRS d. Determine if there is a QRS for every P wave
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? a. Document your findings as normal b. Assess for an air leak due to bubbling noted in the suction chamber. c. Notify the physician about the drainage. d. Milk the tubing to ensure patency of the tubes
a. Document your findings as normal
What clinical manifestations would you expect to find in a client suffering from Diabetes Insipidus (DI)? (select all that apply) a. Excessive thirst b. Bradycardia c. Dark, cloudy urine d. Decreased blood pressure e. Large volumes of dilute urine
a. Excessive thirst d. Decreased blood pressure e. Large volumes of dilute urine
You are developing a care plan for a patient with SIADH. Which of the following would be a potential nursing diagnosis for this patient? a. Fluid volume overload b. Fluid volume deficient c. Acute pain d. Impaired skin integrity
a. Fluid volume overload
What nursing interventions should be implemented for a client with a hiatal hernia? Select all that apply. a. Have the patient sit up while eating b. Have the patient remain sitting up 1 hour after eating c. Advise the patient to eat frequent/shorter meals d. Keep the head of the bed lowered e. Eliminate problematic foods
a. Have the patient sit up while eating b. Have the patient remain sitting up 1 hour after eating c. Advise the patient to eat frequent/shorter meals e. Eliminate problematic foods
Which of the following signs and symptoms causes concern and requires nursing intervention for a patient who recently had a thyroidectomy? a. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F b. Heart rate of 35, blood pressure 60/43, temperature 95.3 'F c. Soft hair, irritable, diarrhea d. Constipation, drowsiness, goiter
a. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a. Increased abdominal and back pain b. Retrosternal back pain radiating to the left arm c. Decreased pulse rate d. Increases respiration
a. Increased abdominal and back pain
A client is admitted to the healthcare facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a. Relieving abdominal pain b. Preventing fluid volume overload c. Maintaining adequate nutritional status d. Teaching about the disease and its treatment
a. Relieving abdominal pain
Which method of wound healing is one in which wound edged are not surgically approximated and integumentary continuity is restored by granulation? a. Second intention healing b. Third intention healing c. First intention healing d. Dehiscence
a. Second intention healing
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? a. Watery with blood and mucus b. Hard and black or tarry c. Dry and streaked with blood d. Loose with visible fatty streaks
a. Watery with blood and mucus
The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? a. "I will need to limit the amount of protein in my diet." b. "I should eat foods that have a lot of potassium in them" c. "I am fortunate that I can eat all the salty foods I enjoy." d. "I am fortunate that I do not need to follow any special diet"
b. "I should eat foods that have a lot of potassium in them"
The physician has ordered aspirin for your patient with acute coronary syndrome. When administering the medication, the patient asks what the aspirin is for. Which of the following is the best response? a. "The aspirin helps reduce inflammation which will protect your heart from further damage." b. "The aspirin will prevent the formation of blood clots." c. "The aspirin will dilate the blood vessels in your heart allowing it to receive more oxygen." d. "The aspirin is the best analgesic for your type of chest pain."
b. "The aspirin will prevent the formation of blood clots."
When no changes are made to the diet or prescribed insulin, which client with type I diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia? a. A 29-year-old with new onset of influenza b. A 40-year-old experienced bicycle rider who adds 10 extra miles to his route c. A 65-year-old with cellulitis in the right leg d. A 72-year-old with emphysema who is taking prednisone
b. A 40-year-old experienced bicycle rider who adds 10 extra miles to his route
Which of the following patients are at risk for developing Cushing's Syndrome. a. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. b. A patient taking glucocorticoids for several weeks. c. A patient with a tuberculosis infection. d. A patient who is post-opt from an adrenalectomy
b. A patient taking glucocorticoids for several weeks.
Which of the following factors is believed to cause ulcerative colitis? a. Acidic diet b. Altered immunity c. Chronic constipation d. Emotional stress
b. Altered immunity
An elderly client with pneumonia may present with which of the following symptoms first? a. Fever and chills b. Altered mental status and dehydration c. Nausea and vomiting d. Pleuritic chest pain and cough
b. Altered mental status and dehydration
A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? a. Acupuncture b. An exercise routine that includes range-of-motion (ROM) exercises c. Heat therapy and non-steroidal anti-inflammatory medications (NSAIDs) d. Cold therapy
b. An exercise routine that includes range-of-motion (ROM) exercises
The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: 100.2 F, 104 bpm, 22 breaths per min, 128/74 mm Hg. O2 sat is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? a. Hypoxia b. Atelectasis c. Pneumonia d. Fluid overload
b. Atelectasis
The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select All that Apply a. Obtain a midstream urine specimen b. Attach telemetry monitor to the client c. Draw a baseline metabolic panel (BMP) d. Start a saline lock in the right arm e. Request an order for a STAT 12-lead ECG
b. Attach telemetry monitor to the client d. Start a saline lock in the right arm e. Request an order for a STAT 12-lead ECG
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? a. Blood pressure of 120/90 mm Hg b. Blood pressure of 90/50 mm Hg c. Blood pressure of 150/100 mm Hg d. Blood pressure of 110/80 mm Hg
b. Blood pressure of 90/50 mm Hg
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is having a stroke. Which of the following is a possible cause based on the characteristic symptom? a. Large artery thrombosis b. Cerebral aneurysm c. Cardiogenic emboli d. Small artery thrombosis
b. Cerebral aneurysm
A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient? a. Wear a lead apron when providing direct care b. Explain to the patient that she will continue to emit radiation while the implant is in place c. Maintain as much distance as possible from the patient while in the room d. Alert the family members that they should restrict their visits to 5 minutes at one time
b. Explain to the patient that she will continue to emit radiation while the implant is in place
A client with diabetes has a morning glucose of 50. The client is sweaty, cold, and clammy. Which of the following interventions is the most important? a. Recheck the blood glucose b. Give the client ½ cup of fruit juice c. Call the doctor d. Keep the patient NPO
b. Give the client ½ cup of fruit juice
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen
b. Hyperactive bowel sounds in that area
The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? a. I will take my lipid-lowering medicine at the same time each night b. I may experience some discomfort when I eat a high-fat meal c. I need someone to stay with me for about a week after surgery d. I should not splint my incision when I deep breathe and cough
b. I may experience some discomfort when I eat a high-fat meal
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? a. Check the client for peripheral edema & make sure the client takes a diuretic early in the day b. Monitor the client's potassium level & assess the client's intake of bananas & orange juice c. Determine if the client has gained weight & instruct the client to keep the legs elevated d. Instruct the client to ambulate frequently & perform calf-muscle stretching exercises daily Explanation: Th
b. Monitor the client's potassium level & assess the client's intake of bananas & orange juice
A client with acute cholecystitis is experiencing jaundice. Which should the nurse consider as the reason for the jaundice? a. Viral infection of the gallbladder b. Obstruction of the cystic duct by a gallstone c. Accumulation of bile in the hepatic duct d. Accumulation of fat in the wall of the gallbladder
b. Obstruction of the cystic duct by a gallstone
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? a. Call the health care provider b. Place the tube in a bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site
b. Place the tube in a bottle of sterile water
The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? a. Restlessness b. Presence of asterix c. Complains of fatigue d. Decreased serum ammonia levels
b. Presence of asterix
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a. Elevating the head of the bed b. Reinforcing dressings or applying pressure if bleeding is frank c. Rubbing the back Encouraging the client to breathe deeply
b. Reinforcing dressings or applying pressure if bleeding is frank
A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? a. Left side b. Right side c. Prone d. Trendelenburg position
b. Right side
A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result in which laboratory test? a. Serum calcium b. Serum amylase c. Serum bilirubin d. Serum potassium
b. Serum amylase
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a. Confusion or change in mental status b. Severe headache and early change in level of consciousness c. Weakness on one side of the body and trouble speaking d. Foot drop and external hip rotation
b. Severe headache and early change in level of consciousness
A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like, and no bowel sounds are detected. What is the major concern for this patient? a. The patient requires more pain medication b. The patient developed peritonitis c. The patient is developing a paralytic ileus d. The patient has developed renal failure
b. The patient developed peritonitis
The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse? a. Notify the health care provider b. Turn the client from side to side c. Lower the head of the bed d. Push the catheter further into the abdomen
b. Turn the client from side to side
The nurse is instructing the patient with stable angina about the use of nitroglycerin. Which of the following statements, made by the patient, indicates the need for further teaching? a. "When the pain is really bad, I can crush the tablet with my teeth to make it work faster" b. "I will be sure to never remove the pills from the container they are in" c. "I should call my doctor if I experience flushing of the face or a HA" d. "It's probably a good idea to take the medication before I have sex with my wife"
c. "I should call my doctor if I experience flushing of the face or a HA"
A client with varicose veins is scheduled for surgery. Which clinical finding does the nurse expect to identify when assessing the lower extremities of this client? a. Pallor b. Yellowed toenails c. Ankle edema d. Diminished pedal pulses
c. Ankle edema
The client is one hour post endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? a. Instruct the client to cough forcefully b. Encourage early ambulation c. Assess for return of a gag reflex d. Administer held medications
c. Assess for return of a gag reflex
When assessing a patients surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? a. Recheck in 1 hour for increased drainage b. Notify the surgeon of a potential hemorrhage c. Assess the patient's blood pressure and heart rate d. Remove the dressing and assess the surgical incision
c. Assess the patient's blood pressure and heart rate
During the first 24 hours after a client is diagnosed with Addisonian crisis, which intervention should the nurse perform frequently? a. Weigh the client b. Test urine for ketones c. Assess vital signs d. Administer oral hydrocortisone
c. Assess vital signs
Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier? a. Fingers pink and warm and move freely b. Radial pulses palpable and +2 bilaterally c. Capillary refill of left fingers greater than 3 seconds d. Absence of numbness and tingling
c. Capillary refill of left fingers greater than 3 seconds
Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse will position the lower extremities in what position? a. Dependent position b. Horizontal position c. Elevated position above heart level d. Knee flexed position
c. Elevated position above heart level
A male client in his late 50s presents with lower urinary tract symptoms (weak urine flow, nocturia, etc). He is diagnosed with BPH and is asking his nurse about lifestyle modifications he should undergo to manage his symptoms. What statements are accurate? Select all that apply. a. He should reduce his intake of protein b. He should switch from his intensive exercise routine to a more moderate one c. He should look into drinking cessation options d. He should eat more fruits and vegetables
c. He should look into drinking cessation options d. He should eat more fruits and vegetables
A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes? a. Numbness b. Fatigue c. Increased hunger d. Dizziness
c. Increased hunger
A patient with chronic obstructive pulmonary disease (COPD) complains of dry mouth, blurry vision, cough, and difficulty urinating but cannot recall the name of the inhaler that was recently prescribed. Which drug does the nurse determine the patient is likely receiving based on the symptoms? a. Albuterol b. Fluticasone c. Ipratropium d. Theophylline
c. Ipratropium
Which of the following diet modifications would be used as treatment in a client with Conn's syndrome? a. High protein b. Low fat and low carbohydrates c. Low sodium d. Low protein
c. Low sodium
A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability? a. Produce a new hormone to try and regulate the thyroid function b. Stimulate more hormones using the positive feedback system c. Stimulate more hormones using the negative feedback system d. The feedback loop will be unable to perform in response to low levels of thyroid hormones
c. Stimulate more hormones using the negative feedback system
The nurse is reviewing the patients on the medical floor. Which client should the nurse assess first? a. The client with congestive heart failure who is being discharged in the morning b. The client who is having frequent incontinent liquid bowel movements & vomiting c. The client with an apical pulse rate of 116, a respiratory rate of 26, & a blood pressure of 94/62 d. The client who is complaining of chest pain on inspiration & a nonproductive cough
c. The client with an apical pulse rate of 116, a respiratory rate of 26, & a blood pressure of 94/62
The client has six (6) hours postoperative open cholecystectomy and the nurse finds a large amount of red drainage on the dressing. Which intervention should the nurse implement? a. Measure the abdominal girth b. Palpate the lower abdomen for a mass c. Turn the client onto the side to assess for further drainage d. Remove the dressing to determine the source
c. Turn the client onto the side to assess for further drainage
A patient presents to the ER with with pain that occurs after eating and diarrhea that is not relieved by defecation. After assessing the patient, there is a diagnosis of Crohn's disease. Which complication should the nurse watch for? a. hyperthermia b. dehydration c. fistula formation d. increased risk of prostate cancer
c. fistula formation
You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? a. Reposition the patient because the tubing is kinked. b. Continue to monitor the drainage system. c. Increase the suction to the drainage system until the bubbling stops. d. Check the drainage system for an air leak.
d. Check the drainage system for an air leak.
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? a. Heart rate of 100 b. Respiration of 22 c. Systolic pressure of 130mmHg d. Diastolic pressure of 110mmHg
d. Diastolic pressure of 110mmHg
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY?* a. Place the patient in supine position and clamp the tubing. b. Notify the physician immediately. c. Disconnect the drainage system and get a new one. d. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
d. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
