Alterations Final
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO 2 89 mm Hg, PCO 2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? Respiratory alkalosis Poor oxygen perfusion Normal acid-base balance Compensated metabolic acidosis
Normal acid-base balance All data are within expected limits; PO 2 is 80 to 100 mm Hg, PCO 2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within the expected limits of 80 to 100 mm Hg. With metabolic acidosis, the pH is less than 7.35.
A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. Which instructions should the nurse include in the client's discharge teaching? Select all that apply. Encourage to quit smoking Elevate the foot of the bed Avoid caffeine-containing products Eat three large, evenly spaced meals daily Avoid lying down for 2 to 3 hours after eating
Encourage to quit smoking Avoid caffeine-containing products Avoid lying down for 2 to 3 hours after eating Smoking cessation should be encouraged. Caffeine should be avoided because it decreases esophageal sphincter pressure, which permits reflux. Advise the client not to lie down for 2 to 3 hours after eating. Coffee and tea contain caffeine, which decreases esophageal sphincter pressure and should be avoided; milk does not have to be eliminated from the diet unless the client has lactose intolerance. The head, not the foot, of the bed should be elevated to prevent nighttime reflux; at night infrequent swallowing and the recumbent position impair esophageal clearance. Three large meals increase the volume pressure in the stomach, which delays gastric emptying; four to six smaller meals are preferred.
A nurse is caring for a client with Cushing syndrome. Which cardiovascular complication should the nurse assess for in this client? Chest pain Tachycardia Hypertension Atrial fibrillation
Hypertension Hypertension is a cardiovascular complication found in clients with Cushing syndrome due to increased metabolic demands and catecholamines. Chest pain is seen in clients with hyperthyroidism and hypothyroidism. Tachycardia and atrial fibrillation are manifestations of dysrhythmias, which are associated with hypothyroidism or hyperthyroidism, parathyroidism, and pheochromocytoma.
After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube? Monitoring the acidity of gastric secretions Providing a route for liquid tube feedings when possible Permitting continuous decompression of the large intestine Removing fluids and gas from the upper gastrointestinal tract
Removing fluids and gas from the upper gastrointestinal tract A nasogastric tube removes fluids and gas from the upper gastrointestinal tract, which improves healing of the surgical area and minimizes nausea. Monitoring the acidity of gastric secretions is not the purpose of a nasogastric tube in this situation. Tube feedings are contraindicated after gastrointestinal surgery. The tube decompresses the stomach, not the large bowel.
A nurse has provided teaching to a client with a newly prescribed proton pump inhibitor (PPI). The nurse determines that the teaching is effective when the client states that the medication is used for the treatment of which condition? Diarrhea Vomiting Cardiac dysrhythmias Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (GERD) PPIs are effective in decreasing the secretion of gastric acid, helping to alleviate symptoms of GERD. PPIs are not used for the treatment of diarrhea, vomiting, or cardiac dysrhythmias.
A mother whose school-aged son has acute glomerulonephritis (AGN) is fearful that her other children may contract the disorder. What should the nurse tell the mother about the origin of acute glomerulonephritis? "The disorder is difficult to prevent because the cause is unknown." "It is a result of an autoimmune response after a streptococcal infection." "It is transmitted through a sex-linked chromosome that occurs only in males." "The disorder is caused by clot formation in the kidney tubules as a response to an infection."
"It is a result of an autoimmune response after a streptococcal infection." The beta-hemolytic streptococcal immune complex becomes trapped in the glomerular capillary loop, resulting in acute poststreptococcal glomerulonephritis. The cause of AGN is known; prevention depends on treating individuals who contract streptococcal infections with antibiotics. AGN is not inherited; it is an acquired disease. Incidence in males outnumbers that in females by a 2:1 ratio. The precipitating streptococcal infection usually is a localized pharyngitis, and clots do not form in the renal tubules.
The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. Confusion Hyperactivity Excessive thirst Fruity-scented breath Decreased urinary output
Confusion Excessive thirst Fruity-scented breath Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.
The nurse is caring for a client with peritonitis who had surgery two hours ago due to a ruptured appendix. Which clinical findings should the nurse expect to observe when assessing this client? Select all that apply. Fever Hyperactivity Extreme hunger Urinary retention Abdominal muscle rigidity
Fever Urinary retention Abdominal muscle rigidity The nurse is assessing a client with peritonitis who is also recovering from surgery that occurred two hours ago for a ruptured appendix. The nurse should expect to observe a fever and abdominal muscle rigidity from peritonitis and urinary retention as a complication of surgical anesthesia. A fever is associated with peritoneal membrane inflammation and a moderate fever is also a common post-surgical assessment finding. Abdominal rigidity over the affected area is a classic sign of peritonitis. Malaise, fatigue (not hyperactivity), and nausea (not hunger) are the expected findings with peritonitis and during surgical recovery.
An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? Low-fat High-fiber High-protein Low-carbohydrate
High-fiber A high-fiber diet is recommended for diverticulosis. Fiber promotes passage of residue through the intestine, thereby preventing constipation. Constipation causes straining at stool; this increases intraluminal pressure, which can precipitate diverticulitis or perforation of diverticula. The other diets are not indicated for diverticulosis.
A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder? Diarrhea and pyrexia Edema and hypertension Moon face and hirsutism Hypoglycemia and hypotension
Hypoglycemia and hypotension Adrenocortical insufficiency causes decreased glucocorticoids, resulting in hypoglycemia; also, it causes decreased aldosterone, resulting in fluid excretion that leads to hypotension. Although diarrhea can occur initially with steroid replacement, it should subside; pyrexia will occur only if there is a concomitant infection. Edema and hypertension are not related to Addison disease; they are associated with Cushing disease, because of excessive cortisol and aldosterone, resulting in fluid and sodium retention. Moon face and hirsutism are related to Cushing disease, not Addison disease; moon facies is caused by adipose tissue deposition, and hirsutism is caused by excessive androgen secretion.
A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? Inclusion of transmural involvement of the small bowel wall Higher occurrence of fistulas and abscesses from changes in the bowel wall Pathology beginning proximally with intermittent plaques found along the colon Involvement starting distally with rectal bleeding that spreads continuously up the colon
Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.
A client is admitted to the hospital with a possible diagnosis of Addison disease. What is an important nursing responsibility during a 24-hour urine collection for this client? Keeping the client quiet and reducing stress Assessing the client for signs and symptoms of edema Monitoring the client for an elevation in blood pressure Restricting the client's fluid intake during the day of the test
Keeping the client quiet and reducing stress Stress and activity increase the secretion of adrenocorticotropic hormone (ACTH) and adrenocortical hormones, elevating the urine values for the by-products of these hormones, thus invalidating the test results. Clients with Addison disease chronically are dehydrated and do not have edema. Because of fluid deficits, the client will be hypovolemic, and the blood pressure will be decreased. Adequate fluid intake is necessary for urine production; Addison disease involves salt wasting and dehydration, which necessitates an increased fluid intake, not a restriction of fluid intake.
Which is the priority intervention for the dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? Apply oxygen Place the client in a side-lying position Prepare to administer packed red blood cells Assess the client's pulse and blood pressure
Place the client in a side-lying position Recall the airway, breathing, and circulation (ABCs) of priority care. The client who needs assistance to manage self-care (dependent) should be placed in the side-lying position when vomiting to prevent aspiration. The use of supplemental oxygen may support oxygen saturation in the client with decreased hemoglobin because of gastrointestinal bleeding. However, in the dependent client who is vomiting, applying oxygen is of lower priority than placing the client in a side-lying position. The nurse should anticipate a prescription for packed red blood cells in the client with a significant gastrointestinal bleed. Restoring circulation, however, is of lower priority than protecting the airway in a dependent client whose airway is at risk. The immediate physical examination of the client with active gastrointestinal bleeding includes evaluation of vital signs as a means of assessing for shock. Assessing for adequate circulation does not take priority over protecting the airway.
A nurse is reviewing the laboratory reports of a client with a diagnosis of end-stage renal disease. Which test result should the nurse anticipate? Arterial pH of 7.5 Hematocrit of 54% Potassium of 6.3 mEq/L (6.3 mmol/L) Creatinine of 1.2 mg/dL (106 mcmol/L)
Potassium of 6.3 mEq/L (6.3 mmol/L) Clients with end-stage renal disease have impaired potassium excretion, so the nurse should anticipate a potassium level more than the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clients with end-stage renal disease usually have a serum pH that is less than 7.35 because of metabolic acidosis. A pH of 7.5 that exceeds the expected range of 7.35 to 7.45 is not anticipated because this is alkalosis. Clients with end-stage renal disease have decreased erythropoietin, which leads to decreased red blood cell production and hematocrit; a hematocrit of 54% exceeds the expected range, which is 39% to 50% for males and 35% to 47% for females; therefore, it is not anticipated. Clients with end-stage renal disease have a decreased ability to eliminate nitrogenous wastes, which leads to increased creatinine levels; a creatinine level of 1.2 mg/dL (106 mcmol/L) is within the expected range of 0.7 to 1.4 mg /dL (62 to 124 mcmol/L) and therefore is not anticipated.
The nurse is caring for a client who has been diagnosed with glomerulonephritis. Which initial urinary finding supports this diagnosis? Anuria Dysuria Polyuria Proteinuria
Proteinuria Protein in the urine (proteinuria) and hematuria (blood in the urine) are classic manifestations of the onset of glomerulonephritis because of the increased permeability of the vascular bed in the kidneys. Suppression of urine formation (anuria) is not an initial manifestation of glomerulonephritis; oliguria may be present. Pain or burning on urination (dysuria) is indicative of cystitis, not glomerulonephritis. Excessive urination (polyuria) does not occur as an initial change with glomerulonephritis; polyuria and nocturia may occur later with chronic glomerulonephritis, when the renal structures are destroyed.
After reviewing the laboratory reports, the nurse anticipates that the client has renal impairment. Which test reports support the nurse's concern? Select all that apply. Serum albumin: 4.7 g/dL(6.815 µmol/L) Serum creatinine: 2.0 mg/dL (176.8 µmol/L) Serum potassium: 5.9 mEq/L (5.9 mmol/L) Serum cholesterol: 120 mg/dL (3.108 mmol/L) Blood urea nitrogen: 32 mg/dL (11.424 mmol/L)
Serum creatinine: 2.0 mg/dL (176.8 µmol/L) Serum potassium: 5.9 mEq/L (5.9 mmol/L) Blood urea nitrogen: 32 mg/dL (11.424 mmol/L) Renal impairment is marked by increased serum creatinine concentration, blood urea nitrogen, and potassium ion concentration levels. The normal serum creatinine concentration lies between 0.5 and 1.5 mg/dL (44.2-132.6 µmol/L). A serum creatinine value of 2.0 mg/dL (176.8 µmol/L) indicates renal impairment. The normal concentration of potassium ions in serum ranges from 3.5 to 5 mEq/L (3.5-5 mmol/L). A potassium ion concentration of 5.9 mEq/L(5.9 mmol/L) indicates kidney dysfunction. The normal value of blood urea nitrogen (BUN) lies between 7 and 20 mg/dL (2.45-7.14 mmol/L). A BUN value of 32 mg/dL (11.424 mmol/L) indicates renal impairment. The normal range of serum albumin concentration lies between 3.5 to 5.5 g/dL (5.075-7.975 µmol/L). A cholesterol value less than 200 mg/dL (5.18 mmol/L) is normal.
A mother brings her 6-year-old child to the pediatric clinic, stating that the child has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. What additional information should the nurse obtain that will aid diagnosis? Rash on palms and feet Shoulder and knee pain Recent weight loss of 2 lb (0.9 kg) Strep throat in the past two weeks
Strep throat in the past two weeks The smoky urine and the stated symptoms should lead the nurse to suspect glomerulonephritis, which usually occurs after a recent streptococcal infection. A rash on the hands and feet is associated with scarlet fever, not glomerulonephritis. Shoulder and knee pain is associated with rheumatic fever, not glomerulonephritis. Weight loss generally occurs in children who have type 1 diabetes, not in those with glomerulonephritis.
A 9-year-old child is found to have acute glomerulonephritis after a recent infection. What microorganism should the nurse suspect as the cause of the child's current health problem? Haemophilus Streptococcus Pseudomonas Staphylococcus
Streptococcus Acute glomerulonephritis, an immune complex disease, is a reaction that occurs as a sequela of streptococcal infection; it is known as acute poststreptococcal glomerulonephritis. Haemophilus is associated with conjunctivitis and meningitis, not with glomerulonephritis. Pseudomonas is associated with many diseases of human beings but not with glomerulonephritis in children. Staphylococcus is associated with localized suppurating infections, not with glomerulonephritis.
A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. What does the nurse expect the child's mother to report? The child had a sore throat a few weeks ago. The child has just recovered from the measles. The child's father has a family history of urinary tract infections. The child's immunizations were administered at the start of school.
The child had a sore throat a few weeks ago. Acute poststreptococcal glomerulonephritis (APSGN) is associated with a history of streptococcal infection of the throat. The measles virus is not associated with the development of APSGN. APSGN is not an inherited disease. No immunizations can cause glomerulonephritis.
A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. Emaciation Weakness Hypertension Truncal obesity Intermittent tonic spasms
Weakness Hypertension Truncal obesity Weakness occurs in response to the excessive catabolism of proteins and resulting loss of muscle mass. Hypertension occurs in response to excessive cortisol that causes an increase in circulating volume or an arteriole response to circulating catecholamines. Truncal obesity is caused by abnormal fat metabolism and deposition of fat in the mesenteric bed. Emaciation is associated with Addison disease. Intermittent tonic spasms of the extremities are associated with tetany, a neuromuscular manifestation, because of a decrease in ionized calcium occurring in hypoparathyroidism, not Cushing syndrome.
What clinical indicators should a nurse assess when caring for a client with hyperthyroidism? Select all that apply. Dry skin Weight loss Tachycardia Restlessness Constipation Exophthalmos
Weight loss Tachycardia Restlessness Exophthalmos Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema. Dry, coarse, scaly skin occurs with hypothyroidism, not hyperthyroidism, because of decreased glandular function. Smooth, warm, moist skin occurs with hyperthyroidism. Constipation is associated with hypothyroidism. Increased stools and diarrhea are associated with hyperthyroidism.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruits and vegetables Nuts and seeds Lean red meats Milk and eggs
Whole grains Cooked fruits and vegetables Nuts and seeds Milk and eggs With diverticular disease, the client should avoid foods that may obstruct the diverticula; therefore, the fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. Although it has been believed in the past that avoiding nuts and seeds would prevent diverticulitis, there is no evidence to support this claim and nuts and seeds can be consumed as long as they are thoroughly chewed. For clients with diverticular disease, the client should decrease intake of fats and red meats.
A 9-year-old child with type 1 diabetes is admitted to the hospital with deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. What laboratory findings is the nurse most likely to observe? pH 7.25; glucose 60 mg/dL (3.3 mmol/L) pH 7.50; glucose 60 mg/dL (3.3 mmol/L) pH 7.25; glucose 460 mg/dL (25.5 mmol/L) pH 7.50; glucose 460 mg/dL (25.5 mmol/L)
pH 7.25; glucose 460 mg/dL (25.5 mmol/L) The clinical manifestations indicate ketoacidosis, so these values are expected; the pH of 7.25 indicates acidosis (metabolic or ketoacidosis), and the blood glucose level of 460 mg/dL (25.5 mmol/L), higher than the expected range of 70 to 105 mg/dL (3.9 to 5.8 mmol/L), indicates severe hyperglycemia. Although the blood pH of 7.25 indicates acidosis, the blood glucose level of 60 mg/dL (3.3 mmol/L) is below the expected range of 70 to 105 mg/dL (3.9 to 5.8 mmol/L); with ketoacidosis, the child will be hyperglycemic. Both the pH of 7.50 and the glucose level of 60 mg/dL (3.3 mmol/L) are unexpected with ketoacidosis; with ketoacidosis, the pH is decreased and the blood glucose level is increased. Although the blood glucose level is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.
Which instructions given to a client with renal calculi would be most beneficial? Select all that apply. "Drink plenty of water." "Have spinach soup every day." "Substitute lemon juice for tea." "Include high amounts of protein in the diet." "Consume foods rich in omega-3-fatty acids."
"Drink plenty of water." "Substitute lemon juice for tea." Renal calculi is the formation of kidney stones. Drinking plenty of water will keep the body hydrated and prevent further formation of stones. Tea contains caffeine, a diuretic, which causes dehydration. Therefore the client must be advised to replace tea with lemon juice. Spinach is rich in oxalates. Consuming spinach soup may aggravate the problem, due to the formation of oxalate crystals. Excessive consumption of proteins may precipitate uric acid stones. Therefore the use of proteins should not be encouraged. Foods rich in omega-3-fatty acids are beneficial in maintaining good health. However, the use of omega-3-fatty acids, specifically in the treatment, mitigation, or prevention of kidney stones, is not justified.
A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. Avoid heavy lifting. Lie down after eating. Avoid drinking alcohol. Eat small, frequent meals. Increase fluid intake with meals. Wear an abdominal binder or girdle.
Avoid heavy lifting. Avoid drinking alcohol. Eat small, frequent meals. Heavy lifting increases intraabdominal pressure, allowing gastric contents to move up through the lower esophageal sphincter (regurgitation), causing heartburn (pyrosis). Alcohol, in addition to peppermints, caffeine, and chocolate, decreases lower esophageal sphincter (LES) pressure, which permits gastric contents to move from the stomach into the esophagus. Eating small, frequent meals limits the amount of food in the stomach, which limits gastroesophageal reflux. Lying down after eating promotes reflux and should be avoided. Increasing fluids with meals increases gastric volume, causing distention and reflux. Constrictive garments, such as belts, binders, and girdles, increase intraabdominal pressure and may lead to reflux.
What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease? Limit physical activity. Restrict sodium in the diet. Continue steroid replacement therapy. Schedule frequent health care appointments.
Continue steroid replacement therapy. Clients with Addison disease must take glucocorticoids regularly to enable them to adapt physiologically to stress and to prevent an addisonian crisis, a medical emergency similar to shock. Activity is permitted as tolerated. Sodium should be taken as desired because hyponatremia frequently occurs from diminished mineralocorticoid secretion. Frequent visits to a healthcare provider are not necessary after control has been established.
A client reports urinary frequency and burning. To determine whether there is tenderness that indicates the presence of an ascending urinary tract infection, the nurse should palpate which area? Tail of Spence Suprapubic area McBurney point Costovertebral angle
Costovertebral angle The costovertebral angle[1][2][3] (the angle formed by the lateral and downward curve of the lowest rib and the vertebral column of the spine itself) is percussed to determine whether there is tenderness in the area over the kidney; this can be a sign of glomerulonephritis or severe upper urinary tract infection. The tail of Spence extends from the upper outer quadrant of the breast to the axillary area; this is the most common site for tumors associated with cancer of the breast. The suprapubic area is above the symphysis pubis; it is palpated and percussed to assess for bladder distention. McBurney's point is 1 to 2 inches (2.5 to 5 cm) above the anterosuperior spine of the ileum on a line between the ileum and umbilicus; external pressure produces tenderness with acute appendicitis, not a kidney infection.
A client is diagnosed with a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report what kind of stools? Frothy Ribbon shaped Pale or clay colored Dark brown or black
Dark brown or black Dark brown or black stools (melena) indicate gastrointestinal bleeding and need to be reported. Frothy stools are indicative of inadequate fat absorption and are associated with sprue. Ribbon-shaped stools indicate a bowel mass or obstruction. Clay-colored stools usually are related to problems that cause a decrease in bile.
A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply. Akinesia Masklike face Postural instability Unilateral limb involvement Increased gait disturbances
Postural instability Increased gait disturbances Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurologic disorders of older adults. Stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. Akinesia is manifested in stage 4 of the disease. Clinical manifestation of stage 2 is "masklike" face. Unilateral limb involvement is seen in stage 1 of Parkinson disease.
A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. Cool skin Photophobia Constipation Periorbital edema Decreased appetite
Cool skin Constipation Periorbital edema Decreased appetite Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.
While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply. Diaphoresis Weight loss Constipation Protruding eyes Cold intolerance
Diaphoresis Weight loss Protruding eyes Diaphoresis occurs with hyperthyroidism because of increased metabolism, resulting in hyperthermia. Weight loss occurs with hyperthyroidism because of increased metabolism. Bulging eyes occur with hyperthyroidism and are thought to be related to an autoimmune response of the retroorbital tissue, which causes the eyeballs to enlarge and push forward. Diarrhea occurs because of increased body processes, specifically increased gastrointestinal peristalsis. Heat intolerance occurs because of the increased metabolism associated with hyperthyroidism.
An emergency department nurse assesses an older client who reports cramping pain in the left lower quadrant, weakness, bloating, and malaise. The client also has a low-grade fever. Which condition does the nurse suspect as the most likely cause of the client's clinical findings? Pancreatitis Appendicitis Cholecystitis Diverticulitis
Diverticulitis Although diverticula can occur at any point within the gastrointestinal tract, they are most common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the left lower quadrant. Pancreatitis is associated with acute epigastric or left upper quadrant pain. Appendicitis is associated with shifting of periumbilical pain to the lower right quadrant and localizing at McBurney's point. Cholecystitis is associated with right upper quadrant pain that may be referred to the right shoulder and scapula.
Which statement by an older adult most strongly supports the nurse's conclusion that the client is impacted with stool? "I have a lot of gas pains." "I don't have much of an appetite." "I feel like I have to go, but I just seep." "I haven't had a bowel movement for several days."
"I feel like I have to go, but I just seep." A client with a fecal impaction has the urge to defecate but is unable to do so, and liquid stool seeps around the impaction. Flatulence may occur as a result of immobility, not just obstruction. Anorexia may occur with an impaction but also may be caused by other conditions. The frequency of bowel movements varies for individuals; it may be normal for this individual not to have a bowel movement for several days.
A client who was admitted to the hospital with a diagnosis of a renal calculus is successful in passing the stone. The nurse is preparing the client for discharge and should include what in the client's instructions? "Strain all urine." "Increase fluid intake." "Limit dietary potassium." "Maintain bed rest for 24 hours."
"Increase fluid intake." Increasing fluid intake[1][2] prevents stagnation of urine, which reduces the risk of precipitates forming calculi. The client has already passed the stone; straining all urine is unnecessary once calculi are removed or passed. Potassium is not restricted in the diet. The client can return to usual activities because the stone was passed; bed rest is not advised because it causes urine to stagnate, predisposing to calculi formation.
A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction? "Restrict fluid intake." "Take showers instead of bubble baths." "Avoid situations that involve physical activity." "Seek early treatment for respiratory infections."
"Seek early treatment for respiratory infections." A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis. The alkalinity of bubble baths is linked to urinary tract infections, not glomerulonephritis. Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection.
A 5-year-old child is admitted to the pediatric unit complaining of colicky abdominal pain with guarding, nausea, anorexia, and a low-grade fever. Palpation of the right lower quadrant of the abdomen elicits pain. What is the most likely diagnosis the nurse should expect when planning care for this child? Ulcerative colitis Acute appendicitis Hirschsprung disease Hookworm infestation
Acute appendicitis These are the classic signs and symptoms of acute appendicitis; they are caused by inflammation and altered gastrointestinal functioning. The child will have diarrhea with ulcerative colitis. The child's adaptations do not indicate the constipation associated with Hirschsprung disease. The adaptations to hookworm infestation are anemia, malnutrition, and popular eruptions.
A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder? Select all that apply. Anemia Diarrhea Hemoptysis Abdominal cramps Decreased white blood cells
Anemia Diarrhea Abdominal cramps Ulceration of the intestinal mucosa commonly occurs, causing blood loss and anemia. The inflammatory process tends to increase peristalsis, causing diarrhea, electrolyte imbalances, and weight loss. The inflammatory process tends to increase peristalsis, causing abdominal cramping and diarrhea. Coughing up blood from the respiratory tract (hemoptysis) is not associated with colitis. A decreased number of white blood cells (leukopenia) is not associated with colitis.
A client presents with chief complaints of unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, there is truncal obesity with excessively thin extremities, a moon-shaped face, a buffalo hump, thin hair, and adult acne. The symptoms described are suggestive of what disease? Addison disease Cushing disease Multiple sclerosis Kaposi sarcoma
Cushing disease Common symptoms of Cushing disease are weight gain, truncal obesity, buffalo hump, and moon face because of deposits of adipose tissue. The condition is caused by excess cortisol secretion caused by hypersecretion of adrenocorticotropic hormone (ACTH). Other characteristics are diabetes mellitus, muscle wasting, osteoporosis, ecchymosis, and slow healing of wounds. Addison disease is adrenal insufficiency. Symptoms of Addison disease include hypotension, dehydration, hypoglycemia, and hyperpigmentation of the skin. Multiple sclerosis is a progressive disease involving destruction of the myelin sheath, leading to nerve damage. Kaposi sarcoma is a cancer associated with acquired immunodeficiency syndrome (AIDS).
A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? Snack daily in the evenings Divide food into four to six meals a day Eat the last of three daily meals by 8:00 PM Suck a peppermint candy after each meal
Divide food into four to six meals a day The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? Crohn disease Cushing disease End-stage renal disease Gastroesophageal reflux disease
End-stage renal disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.
A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. What symptom might the nurse identify when assessing this client? Fatigue Dry skin Anorexia Bradycardia
Fatigue Excessive metabolic activity associated with hyperthyroidism causes fatigue. Warm, moist skin is expected because of increased peripheral perfusion associated with increased metabolism. Increased appetite is expected because of the increased metabolism associated with hyperthyroidism. Tachycardia is expected because of the increased metabolism associated with hyperthyroidism.
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? Increase oral fluid intake to 2 to 3 L/day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.
Increase oral fluid intake to 2 to 3 L/day. Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.
Famotidine (Pepcid) is prescribed for a client with peptic ulcer disease. The client asks the nurse what this medication does. Which action does the nurse mention when replying? Increases gastric motility Neutralizes gastric acidity Facilitates histamine release Inhibits gastric acid secretion
Inhibits gastric acid secretion Famotidine decreases gastric secretion by inhibiting histamine at H 2 receptors. Increases gastric motility, neutralizes gastric acidity, and facilitates histamine release are not actions of famotidine.
A nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. Orange juice Creamed soup Jelly sandwich Lean roast beef Scrambled eggs
Jelly sandwich Lean roast beef Scrambled eggs A jelly sandwich is low in residue and therefore is less irritating to the colon than other foods. Lean roast beef is low in residue and therefore is less irritating to the colon than other foods. Eggs are low in residue and therefore are less irritating to the colon than other foods. Orange juice contains cellulose (fiber), which is not absorbed and irritates the colon. Milk in creamed soup contains lactose, which is irritating to the colon.
The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? Perform catheter care twice a day. Replace the catheter on a routine basis. Administer cranberry tablets three times each day. Give antibiotics for the duration of catheter placement.
Perform catheter care twice a day. A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter-associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day. Routine replacement of indwelling urinary catheters increases CAUTI risk. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Fluid Protein Sodium Potassium
Protein The waste products of protein metabolism are the main cause of uremia. The degree of protein restriction is determined by the severity of the disease. Fluid restriction may be necessary to prevent edema, heart failure, or hypertension; fluid intake does not directly influence uremia. Sodium is restricted to control fluid retention, not uremia. Potassium is restricted to prevent hyperkalemia, not uremia.
A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? Reduce gastric acidity Reduce colonic irritation Reduce intestinal absorption Reduce bowel infection rate
Reduce colonic irritation A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.
A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide? To augment the immune response To potentiate the effect of antacids To treat Helicobacter pylori infection To reduce hydrochloric acid secretion
To treat Helicobacter pylori infection Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function. Antibiotics do not augment the immune response, potentiate the effect of antacids, or reduce hydrochloric acid secretion.
A client has been taking levothyroxine for hypothyroidism for 3 months. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. Tremors Bradycardia Somnolence Heat intolerance Decreased blood pressure
Tremors Heat intolerance Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, tachycardia, hypertension, heat intolerance, and insomnia. These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.