evolve

The nurse is providing home-going instructions to a female client following a cervical biopsy. Which statement indicates the client understands the instructions? "I can use tampons when bleeding heavily." "I should use antiseptic solutions to clean the perineal region." "I can resume housework tomorrow morning." "I should douche before having intercourse."

"I should use antiseptic solutions to clean the perineal region."

When assessing a client with Graves disease (hyperthyroidism), what would the nurse expect to find in the client's history? Diaphoresis Menorrhagia Dry, brittle hair Sensitivity to cold

Diaphoresis

The nurse is assessing a client with a "moon-shaped" face and thinner arms and legs. Which other assessment findings would the nurse suspect to be present in this client? Select all that apply. Weight loss Gastric ulcer Pain in bones Poor appetite Muscle weakness

Gastric ulcer Pain in bones Muscle weakness

A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client? During the convalescent phase On discharge from the hospital When it is time for a prosthesis

Before the surgery

A client had a colostomy surgery and is learning how to care for the skin around the stoma. Which information should the nurse include in the teaching plan for this client? "Cut an opening about ⅓ inch (0.85 cm) larger than the stomal pattern." "Avoid the use of soap and other irritating agents." "Eat yogurt and drink buttermilk and parsley." "Empty the pouch before it is one-third full."

"Empty the pouch before it is one-third full."

A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the rule of nines to assess the percentage of total body surface area (TBSA) burned. Which percentage should the nurse document in the client's hospital record? 9% 18% 27% 36%

9%

While making rounds, the nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." What should be the nurse's initial action? Call the nurse manager to alert administration. Arrange for the client to be examined by the in-house healthcare provider. Complete an incident report to ensure documentation of the event. Provide information about the incident to the client's primary healthcare provider.

Arrange for the client to be examined by the in-house healthcare provider.

What is a major nursing concern when caring for a client diagnosed with hyperthyroidism? Monitoring for hypoglycemia Protecting visitors and staff from radiation exposure Providing foods to increase appetite Arranging for sufficient rest periods

Arranging for sufficient rest periods

Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method? Aseptic techniques are required. Plants, but not flowers, are allowed. Equipment will be shared with others. Dressings will be changed every 3 days.

Aseptic techniques are required.

A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. What could be the possible condition? Shingles Cellulitis Folliculitis Onychomycosis

Cellulitis

After reviewing the reports of a client, the nurse suspects hypofunctioning of the adrenal gland. Which findings are consistent with hypofunctioning of the adrenal gland? Select all that apply. Increased serum calcium Decreased serum cortisol Decreased serum sodium Decreased serum potassium Increased serum glucose

Increased serum calcium Decreased serum cortisol Decreased serum sodium

The nurse is assessing a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? Select all that apply. Itchy eyes Dry mouth Leukopenia Splenomegaly Photosensitivity

Leukopenia Splenomegaly

A client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease? Diffusion imaging (DI) Magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) Magnetic resonance spectroscopy (MRS)

Magnetic resonance spectroscopy (MRS)

What are the systemic manifestations of acute osteomyelitis? Select all that apply. Malaise Restlessness Night sweats Warmth at the infection site Swelling at the infection site

Malaise Restlessness Night sweats

A client has decreased eccrine and apocrine gland function. During a follow-up visit, the nurse finds that the symptoms have not subsided. Which action of the client might be the reason for this condition? Select all that apply. Use of warm dressings Frequent bathing with hot water Use of soap with high fat content Applying moisturizer before bathing Lowering the water heater temperature

Frequent bathing with hot water Applying moisturizer before bathing

A client who has been diagnosed with a bipolar disorder has been admitted to the psychiatric unit. The nurse recognizes that providing adequate nutrition during the manic phase may be a challenge. Why would adequate nutritional intake be a challenge? The client is too depressed to eat. The client lacks the energy to eat. The client is too busy keeping active to eat. The client is on a restricted diet limiting cheese and other favorite foods.

the client is too busy keeping active to eat.

A client with psoriasis is prescribed corticosteroids. What should be taught to the client for a positive outcome? Select all that apply. "Apply the drug directly to the skin." "Stop the drug when symptoms subside." "Apply the drug using warm or moist dressings." "Apply the drug for shorter periods to each lesion." "Prevent the drug from coming into contact with uninvolved skin."

"Apply the drug directly to the skin." "Apply the drug using warm or moist dressings."

Identify abnormal assessment findings in the client's musculoskeletal system. Select all that apply. Joint crepitation Muscular atrophy Muscle strength of 5 Tenderness of the spine Full range of motion in joints

Joint crepitation Muscular atrophy Tenderness of the spine

The nurse is providing dietary teaching to a client who is receiving hemodialysis. What should the nurse encourage the client to include in the dietary plan? Rice Potatoes Canned salmon Barbecued beef

Rice

What does the nurse instruct a client to do while performing McMurray's test? To raise the leg to 60 degrees To abduct the arm to 90 degrees To flex, rotate, and extend the knees To flex the knee to 30 degrees and pull the tibia forward

To flex, rotate, and extend the knees

A client is diagnosed with pheochromocytoma. Which finding in the urinalysis report supports the diagnosis? Sodium - 200 mmol/24 hr Calcium - 5.6 mmol/24 hr Urea nitrogen - 0.5 mmol/24 hr Total catecholamines - 640 mmol/24 hr

Total catecholamines - 640 mmol/24 hr

Which information may be obtained by palpation? Select all that apply. Turgor Bruises Texture Lesions Moisture content Tissue integrity

Turgor Texture Lesions Moisture content

The nurse is teaching about pneumaturia to a coworker. Which statement should the nurse include in the teaching plan? "It is passage of urine containing gas." "It is stinging pain in the urethral area." "It is the diminished amount of urine in a given time." "It is involuntary urination with increased pressure."

"It is passage of urine containing gas."

A client reports pain in the posterior part of the leg while walking that worsens upon rest. Which musculoskeletal abnormality is present in the client? Crepitus Ankylosis Contracture Achilles tendonitis

Achilles tendonitis

A nurse notes gentamycin in the prescription of an older adult with osteomyelitis. Which nursing interventions should be conducted before starting therapy? Select all that apply. Assessing renal function Assessing hydration status Checking the erythrocyte count Checking the blood platelet count Assessing serum thyroxin levels

Assessing renal function Assessing hydration status

A primary healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing goal for the client during the diagnostic phase? Adhere to a teaching plan. Achieve psychologic adjustment. Maintain present muscle strength. Prepare for the development of myasthenic crisis.

Maintain present muscle strength.

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. What concern about the client requires the nurse to notify the primary healthcare provider? Analgesia and mild sedation will be required to ensure rest. Steroid replacement medication therapy will have to be reduced. There is a decreased ability to handle stress despite steroid therapy. Feelings of exhaustion and lethargy may result from the emotional stress.

There is a decreased ability to handle stress despite steroid therapy.

Which is a clinical manifestation of the Landouzy-Déjérine type of muscular dystrophy (MD)? Loss of hearing Cardiomyopathy Respiratory failure Mental impairment

Loss of hearing

The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor? Genetic valvular heart disease Atherosclerotic plaques within arteries Developmental defects in arterial walls Multiple emboli ascending from the lower extremities

Atherosclerotic plaques within arteries

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.

A client has a long leg cast. What instructions should the nurse give the client in preparation for crutch walking? Use the trapeze to strengthen the biceps. Keep the affected limb in extension and abduction. Sit up straight in a chair to develop the back muscles. Perform exercises in bed to strengthen the upper extremities.

Perform exercises in bed to strengthen the upper extremities.

An older client has decreased blood flow to the nails. Which nursing action would be most effective for the client? Determining rate of nail growth Cutting the toenail straight across Assessing for cyanosis using oral mucosa Checking capillary refill using fingernails

Assessing for cyanosis using oral mucosa

A client with ascites is scheduled to have a paracentesis. What should the nurse include in the plan of care? Instruct the client to urinate before the procedure. Shave hair around the insertion site and 2 to 3 inches (5 to 7.5 cm) beyond the site. Position the client on the side with the hips and knees flexed during the procedure. Measure the abdominal girth two fingerbreadths below the umbilicus immediately before the procedure.

Instruct the client to urinate before the procedure.

While grading a client's muscle strength, the nurse records a score of 4. What does this indicate? No detection of muscular contraction A barely detectable flicker or trace of contraction Active movement against gravity and some resistance Active movement against gravity only, not against resistance

Active movement against gravity and some resistance

Which medication used to treat urinary incontinence strengthens the urinary sphincters and has anticholinergic action? Midorine Duloxetine Oxybutynin Mirabegron

Duloxetine

A client's laboratory report shows altered serum calcium concentration. Which hormones are responsible for this condition? Select all that apply. Calcitonin Thyroxine Glucocorticoids Growth hormone Parathyroid hormone

Calcitonin Parathyroid hormone

The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client? Select all that apply. Performing keratoplasty Performing phacoemulsification Monitoring for pain and eye redness Monitoring the client's blood glucose levels Assessing if the client is under antiplatelet medication

Monitoring the client's blood glucose levels Assessing if the client is under antiplatelet medication

While assessing the skin of a client, the nurse observes weeping papules, fissuring, and lichenification on the client's foot. What could be the possible diagnosis of the client? Drug eruption Atopic dermatitis Contact dermatitis Non-specific eczematous dermatitis

Non-specific eczematous dermatitis

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery? Remain flat for three hours Eat a soft diet for two days Breathe and cough deeply Avoid bending from the waist

Avoid bending from the waist

Which treatment intervention should be provided to a client diagnosed with Cushing's disease? Increase cortisol levels Increase sodium levels Decrease blood glucose levels Decrease serum calcium levels

Decrease blood glucose levels

The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client? Nitrofurantoin Mafenide acetate Silver sulfadiazine Gentamicin sulfate

Gentamicin sulfate

The nurse is caring for a client with a diagnosis of trachoma. Which drug does the nurse expect to be prescribed by the primary healthcare provider to manage the client's condition? Vidarabine Natamycin Cyclosporine Azithromycin

Azithromycin

While assessing the reproductive health of an older adult female, a nurse finds that the client has an age-related finding. Which finding in the client supports the nurse's conclusion? Breast dimpling Painful intercourse Decreased amount of pubic hair Green discharge from the vulva

Decreased amount of pubic hair

The primary healthcare provider prescribed carbamazepine to a client with central diabetes insipidus. The serum osmolarity is 600 mOsm (mmol)/kg. Which will be an effective outcome of the drug? Decreased thirst Decreased seizures Decreased urine output Increased serum calcium levels

Decreased thirst

Which part of the female external genital protects inner vulval structures and enhances sexual arousal? Clitoris Mons pubis Labia majora Bartholin glands

Labia majora

To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction? Elevate the head of the bed. Add more weight to the traction. Raise the foot of the bed slightly. Tie a chest restraint around the client.

Raise the foot of the bed slightly.

Which glands help in lubricating the urinary meatus in female clients? Skene glands Prostate glands Cowper glands Bartholin glands

Skene glands

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? A raised toilet seat Side rails for the bed A trapeze above the bed Crutches for ambulation

A raised toilet seat

A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis. Which component is increased in the blood and a direct cause of acidosis? Ketones Glucose Lactic acid Glutamic acid

Ketones

A client who is receiving medication for an eye disorder reports bleeding in the eye. Which drug will the nurse most likely observe written in the medication administration record? Ketorolac Trifluridine Natamycin Ciprofloxacin

Ketorolac

A nurse provides discharge instructions to a client who had surgery for a left total hip replacement. Which should the nurse include when teaching the client about how to protect the affected hip when in the sitting position? "When sitting in a soft chair, the left leg should be elevated in a straight-out position." "When sitting in a firm armchair, the left foot should be flat on the floor's surface." "Sit in a firm armchair with the left leg elevated on a high stool." "Sit in a soft chair with pillows tucked under the left hip."

"When sitting in a firm armchair, the left foot should be flat on the floor's surface."

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which outcome would the nurse anticipate? Increased blood urea nitrogen (BUN) Increased serum sodium level Decreased specific gravity Decreased urine output

Decreased urine output

A client who just had a transurethral resection of the prostate reports pain in the operative area. What should the nurse do first? Administer the prescribed analgesic. Inspect the drainage tubing for occlusion. Encourage intake of fluids to dilute urine. Assess vital signs before administering an analgesic.

Inspect the drainage tubing for occlusion.

Shoulder immobilization is prescribed after surgical repair of a client's rotator cuff. Which criterion should the nurse use to determine that appropriate alignment is achieved by the immobilizer device? Forearm moves freely. Upper arm is in abduction. Hand is lower than the elbow. Upper arm lies close to the chest.

Upper arm lies close to the chest.

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? "Urinary control may be permanently lost to some degree." "An indwelling urinary catheter is required for at least a day." "Your ability to perform sexually will be impaired permanently." "Burning on urination will last while the cystostomy tube is in place."

"An indwelling urinary catheter is required for at least a day."

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? "Clients with decreased sensory perception of touch should be carefully monitored for infection." "Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts." "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." "Clients with decreased coordination should be instructed to hold handrails when ambulating."

"Clients with decreased sensory perception of touch should be carefully monitored for infection."

A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. Which information should the nurse include in the home care instructions? "Increase your intake of dairy products for 5 days." "Drink at least 3 L of fluid daily for 4 weeks." "Take no medications after this treatment." "Report blood in the urine immediately."

"Drink at least 3 L of fluid daily for 4 weeks."

A registered nurse teaches a client about the functions of the integumentary system. Which statement made by the client indicates the need for further teaching? "Subcutaneous layer insulates the body." "Sweat glands in the skin aid in homeostasis in the body." "Sebaceous glands in the skin will prevent the hair from drying." "Epidermis of the skin will protect from trauma by providing a cushioning effect."

"Epidermis of the skin will protect from trauma by providing a cushioning effect."

The registered nurse asked the student nurse to care for a client whose dermal-epidermal junction is flattened. On assessing the client, the registered nurse observes that the risk for skin tears is increased. Which action of the student nurse may have resulted in this condition? Taping the client's skin Encouraging the client to take vitamin D supplements Assisting the client to change positions at 4-hour intervals Avoiding the removal of the client's adhesive wound dressings

Assisting the client to change positions at 4-hour intervals

A nurse is assessing a client whose mouth is drooping over to the left. Which cranial nerve should the nurse assess further? Left facial nerve Right facial nerve Left abducens nerve Right abducens nerve

Left facial nerve

Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? Pulse rate Blood pressure Respiratory rate Body temperature

Respiratory rate

A client with arthritis is to begin long-term steroid therapy. Which statement indicates to the nurse that the client understands the instructions about this medication? "My urine may become discolored." "I should avoid crowds in enclosed areas." "Weight loss can occur with this medication." "The medication should be taken between meals."

"I should avoid crowds in enclosed areas."

Among which group of women are breast cancer death rates the lowest? Hawaiian Puerto Rican Asian American African American

Asian American

Which vascular component of the client's nephron delivers arterial blood from the glomerulus into the peritubular capillaries or the vasa recta? Arcuate artery Efferent arteriole Afferent arteriole Interlobular artery

Efferent arteriole

A client reports intolerance to music played at sound levels that do not bother other people. On assessing, the nurse observes impaired hearing in one ear. What could be the possible condition of the client? Vertigo Tinnitus Hyperopia Hyperacusis

Hyperacusis

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention the nurse should expect the primary healthcare provider to prescribe for this client? Intravenous (IV) fluids Potassium NPH insulin (Novolin N) Sodium polystyrene sulfonate (Kayexalate)

Intravenous (IV) fluids

After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? Observing the suprapubic dressing for drainage Maintaining the client in the semi-Fowler position Monitoring for bright red blood in the drainage bag Encouraging fluids by mouth as soon as the gag reflex returns

Monitoring for bright red blood in the drainage bag

A nurse teaches a client about how to protect a skin area that has undergone radiation treatment. Which statement made by the client indicates the nurse needs to follow up? "I should avoid swimming in saltwater." "I should avoid using adhesive bandages." "I should avoid wearing tight-fitting cloth." "I should avoid rinsing the area with the saline solution."

"I should avoid rinsing the area with the saline solution."

A client is treated with a radium implant for cancer of the cervix. Which information is important for the nurse to teach the client when giving discharge instructions? "Limit daily fluid intake." "Return for follow-up care." "Continue a low-residue diet." "Take daily mineral supplements."

"Return for follow-up care."

During an 8-hour shift a client has a 6-oz (180 mL) cup of tea and 360 mL of water; the client vomits 100 mL, and the intravenous (IV) fluids instilled equal the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? 240 mL 340 mL 440 mL 540 mL

440 mL

Which concentration of a client's serum calcium level will stimulate the release of parathyroid hormone? 8.5 mg/dL (0.47 mmol/L) 9.0 mg/dL (0.5 mmol/L) 9.5 mg/dL (0.53 mmol/L) 10.0 mg/dL (0.56 mmol/L)

8.5 mg/dL (0.47 mmol/L)

A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client? Begin helping the client to write. Encourage the client to acknowledge that this disability is permanent. Wait for communication to be initiated by the client even if it takes a long time. Assist family members to accept the fact that they cannot communicate verbally with the client.

Begin helping the client to write.

While interacting with a client who reported visual changes, the nurse finds that the client is frequently exposed to the sun. Which conditions might this client have? Select all that apply. Cataracts Entropion Pterygium Pinguecula Arcus senilis

Cataracts Pterygium Pinguecula

Which drug will the nurse administer to trigger ovulation? Tolvaptan Clomiphene Conivaptan Metyrapone

Clomiphene

A nurse teaches an elderly client safety tip to prevent falls. Which physiologic change may have occurred in the client?> Slowed movement Cartilage degeneration Decreased bone density Decreased range of motion (ROM)

Decreased bone density

A female client reports excessive hair growth on the face and chest. The nurse suspects ovarian dysfunction. Which findings support this assessment? Select all that apply. Deepened voice Enlarged clitoris Capillary fragility Changes in fat distribution Increased thyroid gland activity

Deepened voice Enlarged clitoris

What is the effect of parathyroid hormone on bones? Select all that apply. Increased bone breakdown Increased serum calcium levels Increased sodium and phosphorus excretion Increased absorption of calcium and phosphorus Increased net release of calcium and phosphorus

Increased bone breakdown Increased serum calcium levels Increased net release of calcium and phosphorus

While assessing a client, the nurse observes solar lentigines on the face and back of the hands. What changes in the skin may the nurse suspect to be the reason for the client's symptoms? Increased permeability Decreased extracellular water Decreased activity of sebaceous glands Increased focal melanocytes in the basal layer with pigment accumulation

Increased focal melanocytes in the basal layer with pigment accumulation

A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply. Increased heart rate Increased temperature Decreased respirations Increased pulse deficit Decreased blood pressure

Increased heart rate Increased temperature

A nurse is assessing a client in the outpatient clinic who complains of excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Which sleep disorder is the client experiencing? Nocturia Narcolepsy Sleep apnea Sleep deprivation

Narcolepsy

A primary healthcare provider schedules a bone scan for a client with osteoporosis. Which nursing actions are beneficial for the client? Select all that apply. Placing the client in the supine position Verifying if the client has a shellfish allergy Ensuring that the client has no metal on the clothing Instructing the client to empty the bladder before the scan Informing the client that the postprocedure headache resolves in 2 days

Placing the client in the supine position Instructing the client to empty the bladder before the scan

A nurse is teaching about the function of the loop of Henle. Which function should the nurse include? Secretion of ammonia in the descending limb Secretion of hydrogen in the descending limb Reabsorption of sodium in the ascending limb Reabsorption of water in the ascending limb

Reabsorption of sodium in the ascending limb

When assessing a client, the nurse observes that the client cannot close the right eye. Which cranial nerve should the nurse assess further? Tenth Fourth Second Seventh

Seventh

A client is scheduled to have a thyroidectomy for thyroid cancer. What specific instruction about postoperative care should the nurse provide the client during preoperative teaching? Cough and deep breathe every hour. Perform range-of-motion exercises of the head and neck. Support the head with the hands when changing position. Apply gentle pressure against the incision when swallowing.

Support the head with the hands when changing position.

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? Vitamin C aids in the process of epithelialization. Vitamin C helps in the synthesis of immune factors. Vitamin C increases the metabolic energy required for inflammation. Vitamin C is required for collagen production by fibroblasts.

Vitamin C is required for collagen production by fibroblasts.

A nurse is evaluating the actions of a caregiver for a client with a lower extremity cast. Which action of the caregiver indicates the nurse needs to follow up? Using a towel to dry the cast Moving joints above and below the cast regularly Elevating the injured part above heart level for 48 hours Wrapping the client's cast with a plastic cover for 36 hours

Wrapping the client's cast with a plastic cover for 36 hours

A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. Scaly skin Tenting of skin Transparent skin Increased wrinkles Pigmented lesions

Tenting of skin Transparent skin Increased wrinkles Pigmented lesions

A nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan? The client's airway will remain patent. The client's burns will heal free of infection. The client's urine output will exceed 30 mL every hour. The client's pain will remain at 2 or less on a scale of 0 to 10.

The client's pain will remain at 2 or less on a scale of 0 to 10.

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? Vitamin C aids in the process of epithelialization. Vitamin C helps in the synthesis of immune factors. Vitamin C increases the metabolic energy required for inflammation. Vitamin C is required for collagen production by fibroblasts.

Vitamin C is required for collagen production by fibroblasts.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? Shortening and eventual atrophy of the muscles will occur. Hypertrophy of the muscles eventually will result from disuse. Rigid extension can occur, making therapy painful and difficult. Decreased movement on the affected side predisposes the client to infection.

shortening and eventual atrophy of the muscles will occur.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? Hypertension and bradycardia Flaccid paralysis and numbness Absence of sweating and pyrexia Escalating tachycardia and shock

Hypertension and bradycardia

A client refuses to go to the twice-a-day prescribed sessions in physical therapy. How might the nurse best approach this problem? Having the client observe the progress of a more cooperative client with the same problem Being the client's advocate and asking the primary healthcare provider whether therapy can be decreased to once daily Ensuring that pain medication is administered to the client before the scheduled physical therapy sessions Planning a conference with the client, the physical therapist, and the nurse present to discuss the client's feelings

Planning a conference with the client, the physical therapist, and the nurse present to discuss the client's feelings

A client reports the passage of urine while coughing. What condition does the nurse suspect of the client? Enuresis Pneumaturia Urinary retention Stress incontinence

Stress incontinence

A client has a basal cell carcinoma that is scheduled to be removed. The client expresses concerns that the cancer has metastasized. Which is the best response by the nurse? "You are a low surgical risk." "I can understand how you must feel." "Basal cell tumors usually do not spread." "The primary healthcare provider probably caught it just in time."

"Basal cell tumors usually do not spread."

The nurse provides discharge teaching to a client who had a transurethral vaporization of the prostate. Which statement by the client indicates successful learning? "I should sit for several hours daily." "I should attempt to void every 2 hours when I'm awake." "I should avoid vigorous exercise for 6 months after surgery." "I should notify my primary healthcare provider if my urinary stream decreases."

"I should notify my primary healthcare provider if my urinary stream decreases."

A client with scleroderma is assessed by a speech therapist after choking and having difficulty with chewing and swallowing. Which dietary information should the nurse reinforce with the client? "Ingest semisoft foods for meals." "Take frequent sips of water with snacks." "Maintain three meals per day but chew carefully." "Use a local anesthetic mouthwash before eating."

"Ingest semisoft foods for meals."

A nurse is teaching a safety class about burns. Which examples will the nurse use to describe occupational hazards for burn injuries? Select all that apply. Tar Power lines Fertilizers Radiators Outdoor grills

Tar Power lines Fertilizers

While performing a visual system assessment, the nurse observes that the client has a misalignment of the right eye. The client reports to the nurse, "I am having double vision." What may be the cause of this condition? Myasthenia gravis Periorbital tumors Conjunctival blood vessels rupture Abnormalities of extraocular muscle actions

Abnormalities of extraocular muscle actions

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body. Reduce protein intake to avoid overtaxing the kidneys. Administer the prescribed intravenous fluid with the added vitamin C.

Administer the prescribed intravenous fluid with the added vitamin C.

A client is diagnosed with a pituitary tumor. Which diagnostic test should be prescribed to rule out the probability of an aneurysm prior to surgery for tumor removal? Skull x-ray Angiogram Computed tomography Magnetic resonance imaging

Angiogram

What is the role of unlicensed assistive personnel (UAP) in caring for a client with a cast or in traction? Select all that apply. Applying ice to the cast Positioning the casted extremity above heart level Marking the circumference of any drainage on the cast Looking for clinical manifestations of compartment syndrome Teaching range-of-motion exercises to the client and caregiver

Applying ice to the cast Positioning the casted extremity above heart level

What is the main reason a nurse raises three of the four side rails on the bed of an 83-year-old client who had surgery for a fractured hip As a safety measure because of the client's age Because clients older than 60 years of age should use side rails To be used as handholds to facilitate the client's ability to move in bed Because all older adults are disoriented for several days after anesthesia

As a safety measure because of the client's age

The nurse is assisting a primary healthcare practitioner to perform an examination of the reproductive tract of a female client. Which nursing action is beneficial for the client? Providing judgmental support to the client Placing the client to move her hands away from the body Asking the client to remove her drape while undergoing the test Asking the client to empty the bladder before the examination

Asking the client to empty the bladder before the examination

A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important initial nursing intervention for this client? Conveying a positive attitude toward the client Arranging for the client to meet other clients with burns Removing mirrors until the client's physical appearance has improved Reminding family members to avoid comments about the client's appearance

Conveying a positive attitude toward the client

A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply. Ensure that the consent form is signed Assess the client for iodine sensitivity Have the client remove all metal objects Administer an enema or cathartic to the client Instruct the client to lie still during the procedure

Ensure that the consent form is signed Assess the client for iodine sensitivity Administer an enema or cathartic to the client

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? Warm skin at the site of injury Escalating pain in the fingers Rapid capillary refill in affected hand Bounding radial pulse in the injured arm

Escalating pain in the fingers

After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. Which is an expected outcome for this client? Only when pain free, begin exercising as part of a formal activity program. Avoid exercising when there is a moderate amount of discomfort. Exercise and be active unless the discomfort becomes too great. Walk and exercise even when the pain is severe.

Exercise and be active unless the discomfort becomes too great.

A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what? Fold the client's arms across the chest. Place the sling so that the top is below the client's scapulae. Call the primary healthcare provider to secure a prescription to use a mechanical lift. Raise the lift so that the sling is at least 12 inches (30.5 cm) above the mattress.

Fold the client's arms across the chest.

A client reports swelling of the scrotum with no pain. Which condition does the nurse anticipate in the client? Chancroid Hydrocele Spermatocele Incarcerated hernia

Hydrocele

A client with a parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the client's clinical manifestations? Hypercalcemia Hypernatremia Hypermagnesemia Hyperphosphatemia

Hypercalcemia

Which cranial nerve emerges from the client's medulla? Trochlear Trigeminal Hypoglossal Oculomotor

Hypoglossal

While assessing a client, the nurse observes a yellow-orange discoloration in the mucous membranes and sclera. Which underlying cause may be associated if red blood cell hemolysis has occurred? Decreased hemoglobin level Increased serum carotene level Increased blood flow to the skin Increased total serum bilirubin level

Increased total serum bilirubin level

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. What is the origin of the involved nerve? Medulla Midbrain Inferior pons Cerebrum

Inferior pons

What is the role of a Licensed Practical Nurse (LPN) while caring for the client with a cast or traction? Select all that apply. Monitoring skin integrity around the cast Marking circumference of any drainage on the cast Teaching the client and caregiver range-of-motion (ROM) exercises Performing neurovascular assessments on the affected extremity Checking color, temperature, capillary refill, and pulses distal to the cast

Monitoring skin integrity around the cast Marking circumference of any drainage on the cast Checking color, temperature, capillary refill, and pulses distal to the cast

A client who had an open reduction and insertion of a prosthesis for a fracture of the femoral neck is stable after surgery and is returned to the orthopedic unit. What is most important for the nurse to do when positioning this client? Maintain both legs in abduction. Keep both legs in functional body alignment. Avoid placing the client in the supine or prone position. Prevent adduction and external rotation of the affected extremity.

Prevent adduction and external rotation of the affected extremity.

The nurse is caring for a client 4 days after the client had a cystectomy and formation of an ileal conduit. After observing mucous threads in the client's urine, what should the nurse do? Recognize that this is an expected response. Obtain a specimen for culture and sensitivity. Report this to the primary healthcare provider immediately. Increase the client's fluid intake for the next 12 hours.

Recognize that this is an expected response.

Which laboratory finding is a characteristic feature in a client with hypercortisolism? Serum sodium of 150 mEq/L (150 mmol/L) Serum chloride of 100 mEq/L (100 mmol/L) Serum potassium of 4.1 mEq/L (4.1 mmol/L) Serum bicarbonate of 25 mEq/L (25 mmol/L)

Serum sodium of 150 mEq/L (150 mmol/L)

The nurse is caring for a client who may have Paget's disease and osteomalacia. Which laboratory tests can be conducted to confirm the nurse's suspicion? Select all that apply. Aldolase Serum calcium Alkaline phosphatase Lactic dehydrogenase Aspartate aminotransferase

Serum calcium Alkaline phosphatase

The nursing student is teaching a client who has undergone hip replacement surgery. Which instructions from the nursing student indicate a need for correction? Select all that apply. Sit on chairs without arms. Use an elevated toilet seat. Cross legs at the knees or ankles. Use a pillow between legs for the first 6 weeks. Keep hips in a neutral, straight position when sitting.

Sit on chairs without arms. Cross legs at the knees or ankles.

Which finding would the nurse expect in the urinalysis report of a client with diabetes insipidus? pH of urine: 9 Specific gravity of urine: 0.4 Red blood cells in urine: 6 hpf White blood cells in urine: 8 hpf

Specific gravity of urine: 0.4

A nurse administers an estrogen agonist to a client. Which nursing actions would be beneficial? Select all that apply. Observing the client for signs of hypercalcemia Ensuring that the client has a dental examination before starting the drug Teaching the client about signs and symptoms of venous thromboembolism (VTE) Monitoring the client's liver function tests (LFTs) in collaboration with the primary healthcare provider Observing the client for central nervous system (CNS) adverse effects, such as drowsiness, anxiety, and agitation

Teaching the client about signs and symptoms of venous thromboembolism (VTE) Monitoring the client's liver function tests (LFTs) in collaboration with the primary healthcare provider

To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically for the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. When considering care for these sites, which difference will the nurse consider? The graft is more subject to hemorrhage, clotting, and infection than the fistula is. Blood pressure readings can be taken in the arm with the fistula but not the one with the shunt. Intravenous (IV) fluids can be administered in the arm with the shunt but not the one with the fistula. The fistula should be covered with a light dressing, and the shunt should be covered thoroughly with a heavy dressing.

The graft is more subject to hemorrhage, clotting, and infection than the fistula is.

A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma asks the nurse what will happen if surgery is not performed. On what information should the nurse base a response The tumor must be removed to prevent heart and kidney damage. Surgery will prevent the tumor from metastasizing to other organs. Radiation therapy can be just as effective as surgery if the tumor is small. Chemotherapy is as reliable as surgery for the treatment of adenomas of this type in some people.

The tumor must be removed to prevent heart and kidney damage.

During a health fair, the nurse takes an adult's blood pressure, and it is 200/120 mm Hg. The nurse should base the next nursing intervention on what understanding? There is an increased risk for having a cerebrovascular accident (brain attack). Walking around the fair probably raised the blood pressure. The elevated blood pressure reflects the "white coat syndrome." Information should be obtained regarding prescribed medications.

There is an increased risk for having a cerebrovascular accident (brain attack).

A pregnant client is noted to have a yellow-orange discoloration of the ears and nose. On reviewing the laboratory reports, the nurse finds an increase in levels of serum carotene. Which significant condition might be affecting the client? Anemia Liver disorder Erythroderma Thyroid deficiency

Thyroid deficiency

A client with a skin infection on the hand reports itching near the site of infection. Upon assessment, the nurse notices serpiginous patches with elevated borders. What could be the possible diagnosis? Tinea pedis Tinea capitis Tinea manus Tinea corporis

Tinea manus

A client with cancer of the bladder is admitted to the hospital for diagnostic tests to determine the extent of the disease. While the nurse is caring for the client, the client asks, "If they remove my bladder, how will I be able to urinate?" Which is the best response by the nurse? "Dialysis is a likely option." "You can still function normally without a bladder." "The tests will help to determine whether your bladder has to be removed." "A urostomy is a surgical opening that can be created to allow urine to empty into a collection bag."

a urostomy is a surgical opening that can be created to allow urine to empty into a collection bag."

Which skin infection experienced by a client is treated with an intralesional injection? Impetigo Scabies Alopecia areata Bacterial vaginosis

Alopecia areata

A 70-year-old client is diagnosed with cartilaginous degeneration. Which action should the nurse take? Advise the client to use moist heat Teach the client isometric exercises Provide the client with supportive armchairs Demonstrate weight-bearing exercises to the client

Advise the client to use moist heat

The nurse is caring for a client who had a colostomy 36 hours ago. Which nursing intervention is the priority Keeping an accurate record of oral fluid intake Emphasizing the importance of regulating the diet to form stool Teaching care of the incision and how to perform colostomy irrigations Observing for drainage and the condition of the abdominal stoma

Observing for drainage and the condition of the abdominal stoma

To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically for the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. When considering care for these sites, which difference will the nurse consider? The graft is more subject to hemorrhage, clotting, and infection than the fistula is. Blood pressure readings can be taken in the arm with the fistula but not in the one with the shunt. Intravenous (IV) fluids can be administered in the arm with the shunt but not in the one with the fistula. The fistula should be covered with a light dressing, and the shunt should be covered thoroughly with a heavy dressing.

The graft is more subject to hemorrhage, clotting, and infection than the fistula is.

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer? Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution. Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. Discontinue the IV NaCl with 20 mEq KCl solution and replace with IV 5% D 5W solution. Discontinue the IV 5% D 5W with 40 mEq KCl solution and replace with IV 5% D 5W solution.

Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution.

The nurse is performing bedside sonography for a female client who underwent a hysterectomy. Which nursing intervention needs correction? Using the female icon on the bladder scanner Placing an ultrasound gel pad right above the pubic bone Pointing the scan head so the ultrasound is projected towards the client's coccyx Placing the midline of the probe over the abdomen about 1.5 inches (3.8 cm) above the pubic bone

Using the female icon on the bladder scanner

The nurse is assessing a client who is suspected of having candidiasis. Which questions asked by the nurse would help to confirm the diagnosis? Select all that apply. "Do you have interdigital scaling and maceration?" "Do you experience scaliness under the distal nail plate?" "Do you have cheesy plaques in the mouth resembling milk curds?" "Do you have red rashes with satellite lesions around the affected area?" "Do you have white patches in the groin area with increased vaginal discharge?"

"Do you have cheesy plaques in the mouth resembling milk curds?" "Do you have red rashes with satellite lesions around the affected area?" "Do you have white patches in the groin area with increased vaginal discharge?"

Which nursing action would be most effective in reducing complications in an older client who has decreased cell division in the epidermal layer of the skin? Select all that apply. Advising the client to prevent skin trauma Advising the client to protect open areas Assessing for excessive dryness or moisture Handling the client carefully to reduce skin friction Advising the client to change positions every 2 hours

Advising the client to prevent skin trauma Advising the client to protect open areas

A nurse is caring for a client after a thyroidectomy. With concerns of nerve injury, what functional ability should the client be assessed for? Speaking Swallowing Pursing the lips Turning the head

speaking

The nurse teaches a client about cortisone therapy. Which statements made by the client indicate the need for further teaching? Select all that apply. "I should take three tablets at a time." "I should take the tablet with water." "I should take the tablet twice a week." "I should take the tablet on an empty stomach." "I should take the tablet with a meal."

"I should take three tablets at a time." "I should take the tablet twice a week." "I should take the tablet on an empty stomach."

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number.

3

The nurse is giving discharge teaching to a client with diabetes who has had a hypophysectomy. Which statement made by the client indicates that further teaching is necessary? "There is a risk that I could become permanently sterile." "My insulin dose will need to be increased from now on." "I must have cortisone therapy for the rest of my life." "Life-long thyroxine replacement therapy will be required."

"My insulin dose will need to be increased from now on."

A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? Ambivalent feelings are present and acknowledged. A sedative type of medication has been given recently. A complete history and physical has not been performed and recorded. A discussion of alternatives with two primary healthcare providers has not occurred.

A sedative type of medication has been given recently.

Which wound care is given to a client with severe burn injuries during the acute phase? Assess extent and depth of burns Provide daily shower and wound care Remove dead and contaminated tissue Assess the wound daily and adjust the dressing

Assess the wound daily and adjust the dressing

The registered nurse observes the student nurse caring for the skin of the client who recently underwent radiation therapy. Which actions made by the student nurse should the nurse correct? Select all that apply. Using a washcloth for cleaning the radiated site Rinsing soap thoroughly from the skin of the client Drying the irradiated area with rubbing motions Wearing loose clothing over the skin at the radiation site Removing the ink marks that identify the location of the focused beam of radiation

Using a washcloth for cleaning the radiated site Drying the irradiated area with rubbing motions Removing the ink marks that identify the location of the focused beam of radiation

A registered nurse is teaching a student nurse about factors that influence sleep. Which scenario explained by the registered nurse is an example of a lifestyle factor? "A client complains of trouble falling asleep because he or she is thinking about stress at work." "A client in the intensive care unit says he or she has not been able to sleep properly because of noises and disturbances." "A client who has been taking antidepressants complains of excess drowsiness and lack of sleep." "A client who works irregular rotating overnight shifts complains of difficulty sleeping through the night and fatigue."

"A client who works irregular rotating overnight shifts complains of difficulty sleeping through the night and fatigue."

While assessing a client for hearing acuity, which questions asked by the nurse helps in assessing the personal history of the client? Select all that apply. "Are you diabetic?" "Do you work in a noisy environment?" "Do you have a history of ear infections?" "Do you have a history of diseases due to vitamin C deficiency?" "Do you have a habit of listening to loud music?"

"Are you diabetic?" "Do you work in a noisy environment?" "Do you have a history of ear infections?"` "Do you have a habit of listening to loud music?"

A client with burns is prescribed polymixin by the primary healthcare provider. Which action should the nurse take? Apply the drug every 2-8 hours Leave in place for 7 days Use the drug with barrier dressing Refrain from using with oil-based products

Apply the drug every 2-8 hours

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? Inhibiting urinary tract infections Preventing contractures and atrophy Avoiding flexion or hyperextension of the spine Preparing the client for vocational rehabilitation

Avoiding flexion or hyperextension of the spine

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? Bladder control Nutritional intake Quadriceps setting Use of aids for ambulation

Bladder control

A client has undergone surgery for bags under the eyes. What could be the common complications seen in this client? Select all that apply. Ectropion Visual loss Hematoma Corneal injury Wound infection

Ectropion Hematoma Corneal injury

The nurse is assessing an older adult client with suspected hearing loss. Which observations made by the nurse in the client indicates a decrease in hearing acuity? Select all that apply. Frequent usage of words such as "what" Postural changes while listening to the speaker Bending towards the other person while talking Mismatch in the questions asked and the responses given Startled expression when there is any unexpected sound in the environment

Frequent usage of words such as "what" Postural changes while listening to the speaker Bending towards the other person while talking Mismatch in the questions asked and the responses given

Which actions should the nurse take for a client who underwent cerebral angiography? Select all that apply. Wipe off the gel applied before the test Maintain pressure dressing for two hours Remove the electrodes gently and thoroughly Obtain vital signs and complete neurologic checks Check dressing for bleeding and swelling around the site

Maintain pressure dressing for two hours Obtain vital signs and complete neurologic checks Check dressing for bleeding and swelling around the site

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? Muscle weakness improving after a period of rest Symptoms worse in the morning upon awakening Periods of hyperactivity Slow, insidious onset of muscle weakness

Muscle weakness improving after a period of rest

A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? Refuse to suture wounds Follow the primary healthcare provider's instructions Agree to suture wounds in the primary healthcare provider's presence Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association)

Refuse to suture wounds

During thyroid surgery, a client's parathyroid glands have become damaged. Which condition does the nurse expect the client to develop? Goiter Tetany Globe lag Photophobia

Tetany

A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. Psoriasis Trichinosis Cardiac failure Diabetes mellitus Bacterial endocarditis

Trichinosis Bacterial endocarditis