ADAPTIVE TEST

A nurse is caring for a client with varicose veins. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.) 1 Presence of ankle edema 2 Increased muscle fatigue 3 Diminished peripheral pulses 4 Report of nocturnal leg cramps 5 Leg pain with activity that diminishes with res

1,2,4.Presence of ankle edema , increased muscle fatigue, and a report of nocturnal leg cramps are signs of varicose veins caused by venous dilation resulting from incompetent valves that are expected to prevent backflow. Varicose veins do not affect arterial circulation. Intermittent claudication occurs with decreased arterial, not venous, perfusion.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? (Select all that apply.) 1 Celery sticks 2 Ground beef 3 Fresh salmon 4 Luncheon meat 5 Cooked broccoli

1,4 Celery sticks are high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Beef is lower in sodium than are preserved meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Broccoli does not have significant sodium levels.

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.) 1 Absence of hair on the toes 2 Superficial ulcer with irregular edges 3 Pitting edema of the lower extremities 4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area

1,4 The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. A superficial ulcer with irregular edges is associated with venous insufficiency; the ulcer associated with arterial insufficiency is deep, well demarcated, and may be gangrenous. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency and occurs as a result of degeneration of red blood cells (RBCs) that leak into surrounding tissue.

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." The nurse's initial response should be to: 1 Discuss the client's concerns 2 Clarify the misconception 3 Explain measures to prevent pulmonary emboli 4 Teach recognition of early symptoms of pulmonary emboli

1. Addressing the client's feelings and then exploring preventive measures should reduce anxiety. The risk of a pulmonary embolus is a real concern, not a misconception, associated with thrombophlebitis. Explaining measures to prevent a pulmonary embolus is not the client's concern; this response does not address the client's feelings concerning the risk of sudden death. Teaching recognition of early signs and symptoms of pulmonary emboli disregards the client's expressed fears and may increase anxiety.

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction? 1 Whole milk with oatmeal 2 Garden salad with olive oil 3 Tuna fish with a small apple 4 Soluble fiber cereal with skim milk

1. Although oatmeal is a soluble fiber, whole milk is high in saturated fat and should be avoided. Olive oil contains unsaturated fat. Most fish have a low fat content; fruit does not contain fat. Soluble fiber helps to lower cholesterol; skim milk does not contain fat.

A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations? 1 Hyperventilation 2 Dyspnea 3 Kussmaul respirations 4 Carbon dioxide intoxication

1. The client is hyperventilating and is blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted, this can lead to respiratory alkalosis. Shortness of breath is a sign of dyspnea. There is no evidence that the client is having difficulty breathing. Kussmaul respirations are deep, gasping respirations associated with diabetic acidosis and coma, not hyperventilation associated with anxiety. These clinical manifestations are related to a decreased, not increased, carbon dioxide level in the body. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.

During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1 Interrupt the therapy. 2 Encourage deep breathing. 3 Place the client in the low-Fowler position. 4 Have the client complete the therapy before resting.

1. The client's response indicates lack of physiological tolerance to the procedure, and it must be interrupted. Encouraging deep breathing may be encouraged, but it is not the first intervention. Deep breathing must be done cautiously because it may precipitate respiratory alkalosis . The high-Fowler or orthopneic position is more appropriate for clients who are experiencing cardiopulmonary difficulties. Having the client complete the therapy before resting is contraindicated because the client is not tolerating the procedure. The therapy is intended to clear the respiratory passages of sputum and increase oxygenation. The heart rate should remain the same or decrease, not increase.

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1Syncope 2Headache 3Tachycardia 4Hemiparesis

1. With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node. Hemiparesis is not related to heart block unless decreased cerebral perfusion causes a brain attack.

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? 1 Diuresis and decreased pulse rate 2 Increased blood pressure and weight loss 3 Regular pulse rhythm and stable fluid balance 4 Corrected heart murmur and decreased pulse pressure

1.Digoxin slows the heart rate, which is reflected in a slowing of the pulse; it also increases kidney perfusion, which promotes urine formation, resulting in diuresis and decreased edema. Digoxin will decrease, not increase, the blood pressure; digoxin does promote weight loss through diuresis. Although digoxin produces diuresis as a result of improved cardiac output, which increases fluid output, it does not regulate an irregular pulse. Digoxin will not correct a heart murmur or decrease the pulse pressure.

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. The nurse concludes that the element that most likely contributed to the hyponatremia is: 1Salt intake 2Fluid intake 3Sodium absorption 4Glomerular filtration

2 Hemodilution has occurred because the 1500 mL of intravenous fluid has lowered the serum sodium level. An increase in salt intake is not the cause of the hyponatremia; in addition, the client has not eaten for several days. A decreased, not increased, reabsorption of sodium occurs in acute renal failure. A decreased, not increased, glomerular filtration rate occurs with renal failure.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? (Select all that apply.) 1 Raw carrots 2Boiled spinach 3 Sweet potatoes 4 Brussels sprouts 5 Asparagus spears

2,3. One cup of boiled spinach contains 6.42 mg of iron. One cup of mashed sweet potatoes contains 3.4 mg of iron. One cup of cut carrots contains 1 mg of iron. One cup of Brussels sprouts contains 1.1 mg of iron. One cup of cut asparagus contains 1.2 mg of iron. STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? 1Plaque from within the veins is abraded. 2The dilated saphenous veins are removed. 3Superficial veins are anastomosed to deep veins. 4An umbrella filter is placed in the large affected veins

2. During a ligation, the saphenous vein is removed. Plaque is an arterial, rather than a venous, problem. Anastomosing superficial veins to deep veins is not done during this surgery; superficial and deep veins usually are attached by communicating veins. An umbrella filter placed in the large affected veins prevents emboli from traveling to the lung; it is not a vein ligation and stripping.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1 Elevate the legs and tell the client to drink more fluids. 2 Instruct the client to remain in bed and notify the health care provider. 3 Rub the client's legs to stimulate circulation and cover the client with a blanket. 4 Tell the client about the dangers of prolonged bed rest and encourage ambulation

2. Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Symptoms may indicate a serious problem, and the health care provider must be notified. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present. Bed rest is indicated to prevent the possibility of further damage or creation of an embolus.

A client who is hospitalized after a myocardial infarction asks the nurse why the client is receiving morphine. The nurse replies that morphine: 1 Dilates coronary blood vessels 2 Relieves pain and prevents shock 3 Decreases anxiety and restlessness 4 Helps prevent fibrillation of the heart

2. Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction; it also decreases apprehension and prevents cardiogenic shock. Dilating coronary blood vessels is not the reason for the use of morphine. Decreasing anxiety and restlessness is not the primary reason for the use of morphine. Lidocaine is given intravenously to prevent fibrillation of the heart.

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. The nurse concludes that the severe dyspnea probably is caused by: 1 Abdominal distention or pressure 2 Bronchial obstruction or pleural effusion 3 Fluid retention as a result of renal failure 4 Anxiety associated with pain on inspiration

2. Proliferation of malignant cells may obstruct the bronchial tree or foster development of exudate in the pleural space, decreasing the availability of oxygen and increasing retention of carbon dioxide. A tumor of the lung does not cause abdominal distention or pressure. Fluid retention as a result of renal failure is not associated with cancer of the lung. Although anxiety associated with pain may increase the respiratory rate, it will not cause difficulty with breathing. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The priority nursing intervention is to: 1Turn the client onto the right side 2 Notify the health care provider immediately 3 Document the output as an expected finding 4 Irrigate the drainage catheter to ensure patency

2. Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system; it functions via negative pressure, not gravity. Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.

A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, the nurse on the medical-surgical unit should monitor the client for: 1 Lethargy 2 Tachycardia 3 Deep breathing 4 Abdominal pain

2. Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breathing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss.

A client has a tentative diagnosis of Hodgkin disease. The nurse recalls that the diagnosis is confirmed by a: 1Bone scan 2Lymph node biopsy 3Computed tomography (CT) scan 4Radioactive iodine (131I) uptake study

2. The diagnosis depends on the identification of characteristic histological features of an excised lymph node. A bone scan is a diagnostic device to assess bony metastasis of cancers. CT scans identify the extent of the disease in the abdominal and thoracic cavities. A radioactive iodine (131 I) uptake study is not indicated for Hodgkin disease; it is used for radiotherapy or diagnosis of thyroid diseases.

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client? 1 Increase left ventricular filling and improve cardiac output. 2 Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias. 3 Decrease the workload on the heart and promote maximum coronary artery filling. 4 Increase venous return to the right atrium and increase pulmonary arterial blood flow.

3 With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore, the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and, therefore, oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? (Select all that apply.) 1 Age 2 Height 3 Weight 4 Smoking 5 Family history

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The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be: 1 Ambulated shortly after being transferred to the inpatient room after the procedure. 2 Given a general anesthesia and therefore will be asleep during the procedure. 3 In the supine position with the affected leg extended for several hours postprocedure. 4 Given only clear liquids for the remainder of the procedure day.

3. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. With the femoral approach, bed rest is maintained for several hours. Mild sedation is used for adult clients; the client is conscious. Post-procedural dietary restrictions are minimal, if any.

A client complains of 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. The nurse concludes that further teaching is needed when the client states what? 1"I will wear socks." 2"I will quit smoking." 3"I will elevate my foot." 4"I will increase fluid intake."

3. Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity. Wearing socks should be encouraged because it keeps the feet warm, increasing arterial dilation and perfusion. Smoking cessation is important to increase arterial dilation. Increasing fluid intake decreases the viscosity of blood, possibly preventing thrombus formation, and should be encouraged.

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action is the first line of defense against an emerging influenza pandemic? 1 Complying with quarantine measures 2 Instituting strict international travel restrictions 3 Seeking aid from the international public health community 4 Reporting surveillance findings to appropriate public health official

3. Honesty and openness are essential to understanding the extent of the problem so that an appropriate local and global response can be mobilized to limit emerging pandemics . Although complying with quarantine measures helps, it can only be done in response to detection and reporting of the presence of an emerging health problem. In response to the severe acute respiratory syndrome (SARS) epidemic of 2002, the International Air Transport Association began work to standardize procedures that address passenger screening and the accurate and quick tracking of passenger travel.

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with a history of: 1 Cystitis as an adult 2 Pleurisy as an adult 3 Childhood strep throat 4 Childhood German measles

3. Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered, damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. The nurse evaluates that the teaching was effective when the client says, "I should: 1 Massage my feet and legs with oil or lotion." 2 Apply heat intermittently to my feet and legs." 3 Eat foods high in protein and carbohydrate kilocalories." 4 Control my blood glucose with diet, exercise, and medication.

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A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is: 1 Spasm of the bronchi that traps the air 2 Increase in the vital capacity of the lungs 3 Too rapid expulsion of the air from the alveoli 4 Difficulty in expelling the air trapped in the alveoli

4 Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped.

A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 1 Radiation 2 Burr holes 3 Dermabrasion 4 Laser technique

4. A laser beam causes a thermal inflammatory response, which results in a chorioretinal scar that holds the retina in place. Radiation is not used because it destroys retinal tissue. Burr holes are used in brain, not retinal, surgery. Dermabrasion is used for acne vulgaris and other disfiguring skin conditions, not retinal surgery.

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider? 1 Blurred vision 2 Dizziness on rising 3 Excessive urination 4 Difficulty breathing

4. Dyspnea may indicate development of pulmonary edema, which is a life-threatening condition. Blurred vision may occur in some people, but it is not life-threatening. Dizziness on rising and excessive urination are common side effects of this medication, which are not life-threatening. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? 1Warm, flushed skin 2Increased pulse pressure 3Lethargy with confusion 4Reduced peripheral pulses

4. Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor? 1 "The only times the monitor should be taken off is for showering and sleep." 2 "The monitor will record my activities and symptoms if an abnormal rhythm occurs." 3 "The results from the monitor will be used to determine the size and shape of my heart." 4 "The monitor will record any abnormal heart rhythms while I go about my usual activities."

4. The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

A client with a history of hypertension comes to the emergency department with double vision and a blood pressure of 260/120 mm Hg. The health care provider prescribes a sodium nitroprusside (Nitropress) infusion. The nurse recalls that sodium nitroprusside decreases blood pressure by: 1 Decreasing the heart rate 2 Increasing cardiac output 3 Increasing peripheral resistance 4 Relaxing arterial smooth muscles

4. This drug decreases blood pressure by relaxing venous and arteriolar smooth muscles and is used for immediate reduction of blood pressure. This drug may increase the heart rate as a response to vasodilation. It decreases cardiac workload by decreasing preload and afterload. It decreases peripheral resistance by dilating peripheral blood vessels.

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. The nurse explains that: 1 The client will gain excessive weight if sodium is not limited 2 An inadequate intake of potassium contributed to the disease 3 This type of diet increases emotional stability 4 Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium

Clients with Cushing syndrome or those who are receiving cortical hormones must limit their intake of sodium and increase their intake of potassium because the kidneys are retaining sodium and excreting potassium. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must be considered as well. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.

A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care? 1 Paralysis 2 Infertility 3 Skin lesions 4 Impaired digestion

Pemphigus is primarily a serious disease characterized by blisters filled with fluid. When they are less than 1 cm in diameter, they are called vesicles. When they are larger than 1 cm, they are called bullae. Pemphigus is a disease of the skin. It does not cause paralysis, infertility, or impaired digestion.

A nurse is caring for a client with a pneumothorax that has a chest tube attached to a closed chest drainage system. If the chest tube and closed-chest drainage system are effective, the type of pressure that will be reestablished is 1 Neutral pressure in the pleural space 2 Negative pressure in the pleural space 3 Atmospheric pressure in the thoracic cavity 4 Intrapulmonic pressure in the thoracic cavity

Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? (Select all that apply.) 1 Thirst 2 Anorexia 3 Leg cramps 4 Rapid, thready pulse 5 Dry mucous membranes

The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased peristalsis. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst is associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia. Dry mucous membranes are associated with hypernatremia.