exam 3 study questions

a nurse is assessing a client who has Addison's disease. which of the following findings should the nurse expect? A. hypotension B. weight gain C. sugar craving D. pale skin tone

A; hypotension

a nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the client's vital signs, which of the following actions should the nurse perform next? A. administer nifedipine B. place the client in a high-fowler's position C. check for urinary retention D. check for a fecal impaction

B; place the client in a high-fowler's position

patients with hyperthyroidism are characteristically: A. apathetic and anorexic B. sensitive to heat C. calm D. emotionally stable

B; sensitive to heat

a nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemic-hyperosmolar state. which of the following laboratory findings should the nurse expect? A. serum pH 7.32 B. blood glucose 250 C. blood glucose 425 D. serum pH 7.45

D; serum pH 7.45

early this morning had a subtotal thyroidectomy. during evening rounds, the nurse assesses the client (who now has nausea) and records a temperature of 105 F, tachycardia, and extreme restlessness. what is the most likely cause of these signs? A. tetany B. hypoglycemia C. diabetic ketoacidosis D. thyroid crisis

D; thyroid crisis

a nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. which of the following statements indicates that the client understands the teaching? A. "I'll call the doctor's office if my fingers get colder on the arm with the cast" B. "If i have anything itching under the cast, I'll try to reach the area with a cotton swab" C. "If my fingers swell, i should put a heating pad on them and rest" D. "If i have any tingling under my cast, I'll know i need to move my fingers move"

A; "I'll call the doctor's office if my fingers get colder on the arm with the cast"

a nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. which of the following instructions should the nurse plan to include? A. "take this medication on an empty stomach" B. "take this medication with an antacid" C. "change position slowly while taking this medication" D. "limit your fluid intake while taking this medication"

A; "take this medication on an empty stomach"

which of the following hormones controls secretion of adrenal androgens? A. adrenocorticotropic hormone (ACTH) B. calcitonin C. thyroid-stimulating hormone (TSH) D. parathormone

A; Adrenocorticotropic hormone (ACTH)

a nurse is reviewing the laboratory report of a client who has acute kidney injury. which of the following findings should the nurse expect? (select all that apply) A. BUN 30 B. urine output 40 mL in the past 3 hr C. potassium 3.6 D. calcium 9.8 E. hematocrit 30%

A; BUN 30 B; urine output 40 mL in the past 3 hr E; hematocrit 30%

a nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. which of the following clients should the nurse assess first? A. a client who is difficult to arouse and is unable to respond to questions B. a client who has slurred speech and exhibits anger C. a client who reports nausea and vomiting D. a client who is uncooperative and has uncoordinated movements

A; a client who is difficult to arouse and is unable to respond to questions

a nurse in the emergency department is caring for a client who has fruity breath odor, a dry mouth, and extreme thirst. which of the following assessments should the nurse make? A. blood glucose level B. pupillary reaction to light C. deep tendon reflexes D. liver function tests

A; blood glucose level

the nurse is planning care for a client with Cushing syndrome. which complications will the nurse monitor for in this client? (select all that apply) A. body image changes B. pain management C. risk for infection D. sodium intake E. fluid balance F. potential for injury

A; body image changes C; risk for infection D; sodium intake E; fluid balance F; potential for injury

what interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? A. consume adequate amounts of fluid B. weigh daily C. limit the fluid intake at night D. come to the clinic for IV fluid therapy daily

A; consume adequate amounts of fluid

a nurse is assessing a client who has a head injury with a possible skull fracture. which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve? A. dizziness and hearing loss B. weakness of a side of the tongue C. facial droop and asymmetrical smile D. loss of the same visual field in both eyes

A; dizziness and hearing loss

a nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. which of the following results indicate a therapeutic outcome of insulin therapy? A. fasting blood glucose 96 B. postprandial blood glucose 195 C. random blood glucose 210 D. preprandial blood glucose 60

A; fasting blood glucose 96

a client has been diagnosed with myxedema from long-standing hypothyroidism. what clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? (select all that apply) A. hypothermia B. hypertension C. hypotension D. hypoventilation E. hyperventilation

A; hypothermia C; hypotension D; hypoventilation

a nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. which of the following interventions is the nurse's priority. A. maintain a PaCO2 of approximately 35 B. provide small doses of fentanyl via IV bolus for pain management C. measure body temperature every 1 to 2 hr D. reposition the client every 2 hr

A; maintain a PaCO2 of approximately 35

a client is receiving long-term treatment with high-dose corticosteroids. which of the following would the nurse expect the client to exhibit? A. moon face B. weight loss C. hypotension D. pale thick skin

A; moon face

which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a patient with Cushing's syndrome? A. observe the color of stool B. monitor vital signs every 4 hours C. observe urine output D. monitor bowel patterns

A; observe the color of stool

a nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. which of the following actions should the nurse include in the client's plan of care? A. offering the client a diet high in fluid and fiber B. encouraging active range of motion of the affected leg C. removing the weights prior to positioning the client D. inspecting pin sites every 24 hr for drainage

A; offering the client a diet high in fluid and fiber

a nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. which of the following adverse effects should the nurse include? (select all that apply) A. osteoporosis B. moon-shaped face C. increased risk of infection D. hearing loss E. weight loss

A; osteoporosis B; moon-shaped face C; increased risk of infection

a nurse is reviewing laboratory values for a client who has diabetic ketoacidosis. which of the following results should the nurse expect? A. pH 7.32, PaCO2 36, HCO3 14 B. pH 7.38, PaCO2 55, HCO3 22 C. pH 7.44, PaCO2 40, HCO3 24 D. pH 7.50, PaCO2 42, HCO3 30

A; pH 7.32, PaCO2 36, HCO3 14

a nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. which of the following findings indicate that the client is having a therapeutic response? A. reduction of the effects of thyroid hormone on the heart B. blockage of the release of thyroid hormone from the thyroid gland C. increase in the heart's sensitivity to thyroid hormone D. increase in the uptake of thyroid hormone by the thyroid gland

A; reduction of the effects of thyroid hormone on the heart

a nurse is assessing a client who has a head injury following a motor-vehicle crash. the nurse should identify that which of the following findings indicates increasing intracranial pressure? A. restlessness B. dizziness C. hypotension D. fever

A; restlessness

a nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone. which of the following findings should the nurse report to the provider? A. sodium 110 B. 2+ deep tendon reflexes C. potassium 3.7 D. urine specific gravity 1.025

A; sodium 110

a nurse is caring for a client who has nephrotic syndrome and has been taking prednisone for 3 days. which of the following findings should the nurse report to the provider as an adverse effect of prednisone? A. sore throat B. frequent stools C. hearing loss D. tremors

A; sore throat

a nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. which of the following findings should the nurse report to the provider? (select all that apply) A. tachycardia and hypertension B. respiratory rate 16/min C. negative Chvostek's sign D. laryngeal stridor and hoarseness E. positive Trousseau's sign

A; tachycardia and hypertension D; laryngeal stridor and hoarseness E; positive Trousseau's sign

a nurse is providing teaching to a client who has gout and urolithiasis. the client asks how to prevent future uric acid stones. which of the following suggestions should the nurse provide? (select all that apply) A. take allopurinol as prescribed B. exercise several times a week C. limit intake of foods high in purine D. decrease daily fluid intake E. avoid citrus juices

A; take allopurinol as prescribed B; exercise several times a week C; limit intake of foods high in purine

a nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. which of the following instructions should the nurse include in the teaching? A. "depress the pump once before using the nasal spray for the first time" B. "blow your nose gently prior to using the nasal spray" C. "administer the nasal spray while in a side-lying position" D. "notify the provider if you develop numbness or tingling around the mouth"

B; "blow your nose gently prior to using the nasal spray

a nurse is caring for a client who has been diagnosed with an Addisonian crisis and has a blood pressure of 74/42 mmHg. which of the following prescriptions should the nurse anticipate? A. Desmopressin B. Hydrocortisone C. Dopamine D. Furosemide

B; Hydrocortisone

a nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone secretion with mild manifestations. the nurse should expect the provider to prescribe which of the following medications? A. Chlorpropamide B. Tolvaptan C. Vasopressin D. Desmopressin

B; Tolvaptan

a nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. the client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. which of the following actions should the nurse take first? A. administer an analgesic to the client B. check the client's electrolyte values C. measure the client's weight D. restrict the client's protein intake

B; check the client's electrolyte values

a nurse is planning for a client who has Cushing's syndrome due to chronic corticosteroid use. which of the following actions should the nurse include in the plan of care? A. check the client's blood glucose for hypoglycemia B. check the client's urine specific gravity C. weigh the client weekly D. insert an indwelling urinary catheter for the client

B; check the client's urine specific gravity

a nurse is assessing a client who has diabetes mellitus and reports feeling anxious. which of the following findings should the nurse expect if the client is hypoglycemic? A. rapid, deep respirations B. cool, clammy skin C. abdominal cramping D. orthostatic hypotension

B; cool, clammy skin

a nurse is reviewing the laboratory results of a lumbar puncture for a client who has manifestations of bacterial meningitis. which of the following findings should the nurse expect? A. elevated glucose B. elevated protein C. presence of RBCs D. presence of a D-dimer

B; elevated protein

a nurse in an emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. the client is now disoriented to time and place and has a SaO2 of 87%. the nurse notes generalized petechiae on the client's skin. which of the following complications should the nurse expect? A. hypovolemic shock B. fat embolism syndrome C. thrombophlebitits D. avascular bone necrosis

B; fat embolism syndrome

a nurse is caring for a client who is in skeletal traction following a femur fracture. on entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. which of the following actions should the nurse take? A. remove the weight temporarily to reposition the client to correct alignment in bed B. have the client who has trapeze to pull himself up while ensuring the weight hangs freely C. lift the rope off the pulley while the client rocks back and forth to reposition himself D. lift the weight manually while another staff member moves the client up in bed

B; have the client who has trapeze to pull himself up while ensuring the weight hangs freely

the nurse is assessing a client in the clinic who appears restless, excitable, and agitated. the nurse observes that the client has exophthalmos and neck swelling. what diagnosis do these clinical manifestations correlate with? A. syndrome of inappropriate antidiuretic hormone secretion B. hyperthyroidism C. diabetes insipidus D. hypothyroidism

B; hyperthyroidism

a nurse is assessing a client who has diabetes insipidus. the nurse should expect which of the following findings? A. decreased heart rate B. increased hematocrit C. high urine specific gravity D. low BUN level

B; increased hematocrit

a nurse is planning a teaching for a client who has type 1 diabetes mellitus. which of the following instructions should the nurse plan to include? A. consume no more than 3 servings of alcohol per day B. ingest food with alcohol to reduce alcohol-induced hypoglycemia C. increase insulin dosage before planned exercise D. rest for 3 days between periods of vigorous exercise

B; ingest food with alcohol to reduce alcohol-induced hypoglycemia

a nurse is caring for a client immediately following application of a plaster cast. the nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. sensation of heat on the surface of the cast B. paresthesias of the extremity C. pruritus of the extremity D. musty odor noted from cast materials

B; paresthesias of the extremity

a nurse is assessing a client who is recovering from a thyroidectomy and a harsh, high-pitched respiratory sound. which of the following actions should the nurse take? A. hyperextend the client's neck B. prepare for a tracheostomy C. lower the head of the bed D. administer morphine

B; prepare for a tracheostomy

a client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone. which nursing intervention is appropriate? A. encouraging increased oral intake B. restricting fluids C. infusing IV fluids rapidly as ordered D. administering glucose-containing IV fluids as ordered

B; restricting fluids

a nurse is caring for a client who has a spastic bladder following a spinal cord injury. which of the following actions should the nurse take to help stimulate micturition? A. encourage the client to use the Valsalva maneuver B. stroke the client's inner thigh C. perform the Crede meneuver D. administer a diuretic

B; stroke the client's inner thigh

Dilutional hyponatremia occurs in which disorder? A. Addison disease B. syndrome of inappropriate antidiuretic hormone secretion (SIADH) C. Pheochromocytoma D. Diabetes Insipidus

B; syndrome of inappropriate antidiuretic hormone secretion (SIADH)

a nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. which of the following statements by the client indicates an understanding of the teaching? A. "I should stop taking my insulin if i feel nauseous" B. "I will test my urine for protein when i start to feel ill" C. "I will call my doctor if my blood sugar is more than 250" D. "I should check my blood sugar levels every 8 hours"

C; "I will call my doctor if my blood sugar is more than 250"

which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? A. Graves disease B. Addison disease C. Cushing syndrome D. Hashimoto disease

C; Cushing syndrome

a nurse is assessing a client who has a new diagnosis of Cushing's disease. which of the following findings should the nurse expect? A. decreased blood pressure B. weight loss C. hirsutism D. increased skin thickness

C; Hirsutism

a nurse is caring for a client who has diabetic ketoacidosis. which of the following findings should the nurse expect? A. urine negative for ketones B. distended neck veins C. Kussmaul respirations D. elevated blood pressure

C; Kussmaul respirations

the preferred preparation for treating hypothyroidism includes which of the following? A. radioactive iodine B. Propylthiouracil C. Levothyroxine (synthroid) D. Methimazole (Tapazole)

C; Levothyroxine (synthroid)

a nurse is caring for a client who is postoperative following a frontal craniotomy. the nurse should place the client in which of the following positions? A. Trendelenburg B. Prone C. Semi-Fowlers D. Sims'

C; Semi-Fowlers

a nurse is assessing a client who has Addison's disease. which of the following skin manifestations should the nurse expect to find? A. purple striae on the chest and abdomen B. butterfly rash across the bridge of the nose C. bronze pigmentation of the skin D. jaundice of the face and sclera

C; bronze pigmentation of the skin

surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. during the immediate postoperative period, the nurse knows to elevate serum levels of ______ to assess for a serious and primary postoperative complication of thyroidectomy? A. sodium B. magnesium C. calcium D. potassium

C; calcium

a nurse is assessing a client who has a fractured left femur and is in skeletal traction. which of the following findings should the nurse report to the provider? A. ecchymosis of the thigh B. serous drainage at the pin site C. chest petechiae D. muscle spasms in the left leg

C; chest petechiae

a nurse is caring for a client who has acute kidney injury. which of the following serum laboratory findings should the nurse report to the provider? A. potassium 5 B. calcium 9 C. creatinine 4 D. amylase 84 units

C; creatinine 4

a nurse is teaching a client who has diabetes mellitus about insulin injections. the client's prescriptions includes evening doses of insulin glargine and regular insulin. which of the following instructions should the nurse include? A. inject the insulin intramuscularly B. shake the insulins vigorously prior to administration C. draw up the insulins into separate syringes D. expect the insulins to appear cloudy

C; draw up the insulins into separate syringes

which of the following would the nurse expect to find in a client with severe hyperthyroidism? A. buffalo hump B. tetany C. exophthalmos D. striae

C; exophthalmos

hyperthyroidism is caused by increased levels of thyroxine in blood plasma. a client with this endocrine dysfunction experiences: A. weight gain and heat intolerance B. diastolic hypertension and widened pulse pressure C. heat intolerance and systolic hypertension D. anorexia and hyperexcitability

C; heat intolerance and systolic hypertension

a nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion. which of the following findings should the nurse expect? A. polyuria B. dehydration C. hyponatremia D. hyperthermia

C; hyponatremia

a nurse is assessing a client who recently experienced a head injury. which of the following findings should the nurse identify as an indication of short-term memory impairment? A. inability to remember current age B. inability to count backward C. inability to locate eyeglasses D. inability to recall names of family members

C; inability to locate eyeglasses

a nurse is teaching a client who has hyperthyroidism about managing this disorder. which of the following recommendations should the nurse include? A. reduce total hours of sleep B. keep the immediate environment warm C. increase caloric intake with meals D. gradually increase activity

C; increase caloric intake with meals

cardiac effects of hyperthyroidism include: A. bradycardia B. decreased systolic blood pressure C. palpitations D. decreased pulse pressure

C; palpitations

a nurse is caring for a client who has diabetes insipidus. for which of the following findings should the nurse monitor? A. Proteinuria B. oliguria C. polyuria D. Glycosuria

C; polyuria

a nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure. this increase in ICP is due to which of the following? A. decreased cerebral perfusion B. leakage of cerebral spinal fluid C. rigid skull containing cranial contents D. brain herniated into the brainstem

C; rigid skull containing cranial contents

a nurse is assessing a client who is receiving a transfusion of packed red blood cells. which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. severe hypertension B. low body temperature C. sudden oliguria D. decreased respirations

C; sudden oliguria

a nurse is caring for a client following a thyroidectomy. the nurse should assess for which of the following findings as an indication of hypocalcemia? A. strong, bounding pulse B. decreased bowel sounds C. tingling and numbness of the hands and feet D. diminished deep-tendon reflexes

C; tingling and numbness of the hands and feet

a nurse is admitting a client who has hyperthyroidism. when assessing the client, the nurse should expect which of the following findings? A. cold intolerance B. lethargy C. tremors D. sunken eyes

C; tremors

a nurse is providing teaching to a client who has Addison's disease about healthy snack foods. which of the following food choices by the client indicates an understanding of the teaching? A. sliced bananas B. baked potato C. turkey and cheese sandwich D. plain yogurt with peaches

C; turkey and cheese sandwich

a nurse is assessing a client with hyperthyroidism. what findings should the nurse expect? A. weight gain, constipation, and lethargy B. diaphoresis, fever, and decreased sweating C. weight loss, nervousness, and tachycardia D. exophthalmos, diarrhea, and cold intolerance

C; weight loss, nervousness, and tachycardia

a nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. which of the following information should the nurse include? A. "you will need to apply a cold pack to the site 3 times a day" B. "your provider might ask you to walk frequently to increase circulation to the area" C. "you will need to limit your consumption of high-protein foods" D. "your provider might prescribe a central catheter line for long-term antibiotic therapy"

D; "your provider might prescribe a central catheter line for long-term antibiotic therapy"

a nurse is teaching a client about the adrenocorticotropic hormone stimulation test. the nurse should explain that the purpose of the test is to assess for which of the following disorders? A. diabetes insipidus B. hyperthyroidism C. pheochromocytoma D. Addison's disease

D; Addison's disease

a nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. which of the following laboratory values is consistent with diabetic ketoacidosis? A. blood glucose 30 mg/dL B. negative urine ketones C. blood pH 7.38 D. bicarbonate level 12 mEq/L

D; bicarbonate level 12 mEq/L

a nurse is triaging clients during a mass casualty event. which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? A. red tag B. yellow tag C. green tag D. black tag

D; black tag

a nurse is teaching a client who has diabetes mellitus. which of the following should the nurse include as an expected finding of diabetic ketoacidosis? A. decreased urine output B. weight gain of 1 lb in 24 hr C. rapid, shallow respirations D. blood glucose levels above 300

D; blood glucose levels above 300

a nurse is caring for a client who has a fractured right hip. which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? A. balanced skeletal traction B. pelvic belt C. pelvic sling D. Buck's traction

D; buck's traction

a nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. which of the following assessment findings should the nurse report to the provider? A. glasgow coma scale score of 15 B. intracranial pressure reading of 15 mm Hg C. ecchymosis at base of skull D. clear drainage from nose

D; clear drainage from the nose

a client is being evaluated for hypothyroidism. during assessment, the nurse should stay alert for: A. flushed, warm, moist skin B. exophthalmos and conjunctival redness C. systolic murmur at the left sternal border D. decreased body temperature and cold intolerance

D; decreased body temperature and cold intolerance

during the physical examination of a client with a suspected endocrine disorder, the nurse observes an abnormal bulging of the eyes. the nurse documents this finding as which of the following? A. hypopigmentation B. tremor C. thyroid enlargement D. exophthalmos

D; exophthalmos

a nurse is reviewing the laboratory results of a client undergoing screening for primary Cushing's disease. the nurse should expect an elevation in which of the following laboratory findings? A. lymphocyte count B. potassium C. calcium D. glucose

D; glucose

a nurse is the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting, diarrhea, and abdominal pain. to prevent an Addisonian crisis, the nurse should prepare to administer which of the following medications? A. calcium B. potassium C. Iodine D. hydrocortisone

D; hydrocortisone

a home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. the client has not been taking the medication regularly. which of the following findings should the nurse expect? A. increased urine output B. persistent diarrhea C. tachycardia D. hypotension

D; hypotension

a nurse in the emergency department has assessed a client's airway, breathing, and circulation following a head injury from a fall at work. which of the following actions is the priority for the nurse to perform next? A. question the client's coworkers about the mechanism of injury B. check the client's pupils for equality and reaction to light C. measure the client's alertness using the Glasgow Coma Scale D. immobilize the client's cervical spine

D; immobilize the client's cervical spine

a client is suspected of having central diabetes insipidus and is scheduled to undergo a vasopressin challenge test. when preparing the client for this test, the nurse anticipates that the test would be done A. immediately before bedtime B. in the middle of the afternoon C. just after breakfast D. in the morning after fasting

D; in the morning after fasting

a nurse is assessing a client who has acute kidney injury. according to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? A. < 0.5 mL/kg of urine output for 12 hr B. no urine output for 12 hr C. no urine output without renal replacement therapy for 4 to 12 weeks D. no urine output without renal replacement therapy for more than 3 months

D; no urine output without renal replacement therapy for more than 3 months

a nurse is caring for a client who has urolithiasis and requires further diagnostic testing after an initial test indicated hypercalcemia. which of the following structures controls calcium concentration? A. pancreas B. thyroid gland C. anterior pituitary gland D. parathyroid gland

D; parathyroid gland

a young client has a significant height deficit and is to evaluated for diagnostic purposes. what could be the cause of this client's disorder? A. parathyroid disorder B. adrenal disorder C. thyroid disorder D. pituitary disorder

D; pituitary disorder

a nurse is assessing a client who has a high-thoracic spinal cord injury. the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. flushing of the lower extremities B. hypotension C. tachycardia D. report of a headache

D; report of a headache

a nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. the nurse suspects the client has manifestations of diabetes insipidus. which of the following laboratory values should the nurse plan to obtain to assess for DI? A. BUN B. blood glucose C. urine ketones D. specific gravity

D; specific gravity

a nurse is accepting a transfer from the PACU of a client who has had a subtotal thyroidectomy. which of the following pieces of equipment should the nurse have available at the bedside for this client? A. cardiac monitor B. defibrillator C. thoracotomy tray D. tracheostomy tray

D; tracheostomy tray

most cases of osteomyelitis are caused by which microorganism? A. proteus species B. escherichia coli C. pseudomonas species D. staphylococcus aureus

D; staphylococcus aureus

a nurse is assessing a client who has urolithiasis and reports pain in his thigh. this finding indicates the stone is in which of the following structures? A. ureter B. bladder C. renal pelvis D. renal tubules

A; ureter

a client is admitted with hyperosmolar hyperglycemic nonketotic syndrome. which laboratory finding should the nurse expect in this client? A. BUN 15 mg/dl B. blood glucose level 1,100 mg/dl C. plasma bicarbonate 12 mEq/L D. arterial pH 7.25

B; blood glucose level 1,100 mg/dL

autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? A. T10 B. S2 C. T6 D. L4

C; T6

a nurse is assessing a client who has manifestations of acromegaly. which of the following findings should the nurse expect? A. thinning of skeletal bone structure B. concave chest wall C. high-pitched voice D. increased head size

D; increased head size

A client is admitted to the hospital with a prerenal disorder, a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is:

anaphylaxis

a nurse is assessing a client after a thyroidectomy. the assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. the nurse should suspect which complication? A. tetany B. thyroid storm C. hemorrhage D. laryngeal nerve damage

A; tetany

which may occur if a client experiences compartment syndrome in an upper extremity? A. Volkmann's contracture B. Whiplash injury C. Callus D. subluxation

A; Volkmann's contracture

the earliest sign of serious impairment of brain circulation related to increased ICP is: A. a change in consciousness B. a bounding pulse C. bradycardia D. hypertension

A; a change in consciousness

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? A. administering large doses of IV antibiotics as ordered B. administering large doses of oral antibiotics as ordered C. withholding all oral intake D. instructing the client to ambulate twice daily

A; administering large doses of IV antibiotics as ordered

which of the following is the earliest and most significant sign of increasing intracranial pressure? A. change in level of consciousness B. seizures C. restlessness D. pupil changes

A; change in level of consciousness

a nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy. the nurse should identify that which of the following findings is a priority? A. Dysrhythmias B. pink-tinged urine C. bruising on the flank area D. stone fragments in the urine

A; dysrhythmias

which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis? A. hypokalemia and hypoglycemia B. hypernatremia and hypercalcemia C. hypocalcemia and hyperkalemia D. hyperkalemia and hyperglycemia

A; hypokalemia and hypoglycemia

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply. A. increased T3 B. increases in serum TSH C. increased T4 D. increase in radioactive iodine uptake E. decrease in serum thyroid-stimulating hormone

A; increased T3 C; increased T4 D; increase in radioactive iodine uptake E; decrease in serum thyroid-stimulating hormone

level of consciousness can be assessed based on criteria in the GLasgow Coma Scale. which of the following indicators are assessed in the GCS? (select all that apply) A. motor response B. verbal response C. intelligence D. eye opening E. muscle strength

A; motor response B; verbal response D; eye opening

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: A. myxedema coma B. Hashimoto's thyroiditis C. thyroid storm D. cretinism

A; myxedema coma

the nurse assess a patient who has been diagnosed with Addison's disease. which of the following is a diagnostic sign of this disease? A. potassium of 6.0 mEq/L B. glucose of 100 mg/dL C. a blood pressure reading of 135/90 mm Hg D. Sodium of 140 mEq/L

A; potassium of 6.0 mEq/L

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: A. raccoon's eyes and Battle sign B. motor loss in the legs that exceeds that in the arms C. pupillary changes D. nuchal rigidity and Kernig's sign

A; raccoon's eyes and battle sign

a client with Addison's disease comes to the clinic for a follow-up visit. when assessing this client, the nurse should stay alert for signs and symptoms of: A. sodium and potassium abnormalities B. calcium and phosphorus abnormalities C. chloride and magnesium abnormalities D. sodium and chloride abnormalities

A; sodium and potassium abnormalities

A nurse is performing foot care for a client with chronic osteomyelitis and the client asks the nurse about the next treatment. What is the specific treatment for a client with chronic osteomyelitis? A. surgical removal of the sequesterum B. aggressive physical therapy C. continued aseptic wound treatment D. drainage of localized foci of infection

A; surgical removal of the sequestrum

the nurse auscultates a bruit over the thyroid glands. what does the nurse understand is the significance of this finding? A. the patient may have hyperthyroidism B. the patient may have thyroiditis C. the patient may have hypothyroidism D. the patient may have Cushing disease

A; that patient may have hyperthyroidism

a nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure. which of the following findings indicates that the medication is having a therapeutic effect? A. the client's serum osmolarity is 310 mOsm/L B. the client's pupils are dilated C. the client's heart rate is 56/min D. the client is restless

A; the client's serum osmolarity is 310 mOsm/L

a nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. which of the following findings should the nurse report to the provider? A. toes that are cold to the touch B. serous drainage from the pin sites C. blanching of the toenail beds with pressure D. pink tissue around the fixator insertion sites

A; toes that are cold to the touch

a nurse is assessing a client who has sustained a recent head injury. which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. widened pulse pressure B. tachycardia C. periorbital edema D. decrease in urine output

A; widened pulse pressure

a nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. which of the following findings should the nurse expect? A. elevated blood pressure B. involuntary muscle spasms C. cold intolerance D. weight loss

B; involuntary muscle spasms

during the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? A. administer oral hydrocortisone B. assess vital signs C. test urine for ketones D. weigh the client

B; assess vital signs

you are a neurotrauma nurse working in a neuro ICU. what would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A. paraplegia B. autonomic dysreflexia C. areflexia D. tetraplegia

B; autonomic dysreflexia

the nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. the nurse assesses ecchymosis over the mastoid and clear fluid from the ears. what type of skull fracture is this indicative of? A. temporal skull fracture B. basilar skull fracture C. frontal skull fracture D. occipital skull fracture

B; basilar skull fracture

two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. what will the nurse suspect? A. chronic venous insufficiency B. compartment syndrome C. infection D. phlebitis

B; compartment syndrome

the nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? A. hypertension B. dehydration C. crackles D. hyperkalemia

B; dehydration

a patient has been diagnosed with thyroidal hypothyroidism. the nurse knows that this diagnosis is consistent with which of the following? A. failure of the pituitary gland B. dysfunction of the thyroid gland itself C. inadequate secretion of TSH D. disorder of the hypothalamus

B; dysfunction of the thyroid gland itself

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? A. maintaining the client in semi-fowlers position B. keeping a pillow between the client's legs at all times C. turning the client from side to side every 2 hours D. performing passive range of motion exercises on the client's legs once each shift

B; keeping a pillow between the client's legs at all times

a nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. which of the following measures should the nurse recommend to prevent injuries to the client's feet? A. examine the skin of the feet weekly for alterations in skin integrity B. monitor the temperature of bath water with a thermometer C. shop for shoes early in the day D. round the edges of toenails when trimming them

B; monitor the temperature of bath water with a thermometer

what is a hallmark of the diagnosis of nephrotic syndrome? A. hyponatremia B. proteinuria C. hypokalemia D. hyperalbuminemia

B; proteinuria

in chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? A. wound irrigation B. surgical debridement C. wound packing D. vitamin supplements

B; surgical debridement

A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia? A. Hypothyroidism B. deficient growth hormone C. acromegaly D. type 1 diabetes mellitus

C; acromegaly

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? A. virus B. lymphoma C. bacteria D. leukemia

C; bacteria

A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication? A. blood clot formed in the kidneys interfered with the flow B. obstruction of urine flow from the kidneys C. decrease in the blood flow through the kidneys D. structural damage occurred in the nephrons of the kidneys

C; decrease in the blood flow through the kidneys

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? A. complex regional pain syndrome B. avascular necrosis of bone C. fat embolism syndrome D. compartment syndrome

C; fat embolism syndrome

on the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. when questioned, the client reports numbness and tingling of the mouth and fingertips. suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. which electrolyte disturbance most commonly follows thyroid surgery? A. hyponatremia B. hyperkalemia C. hypocalcemia D. hypermagnesemia

C; hypocalcemia

the nurse is monitoring a patient who sustained a fracture of the left hip. the nurse should be aware that which kind of shock can be a complication of this type of injury? A. cardiogenic B. septic C. hypovolemic D. neurogenic

C; hypovolemic

the nurse is monitoring a patient who sustained a fracture of the left hip. the nurse should be aware that which kind of shock can be a complication of this type of injury? A. neurogenic B. cardiogenic C. hypovolemic D. septic

C; hypovolemic

patients with urolithiasis need to be encouraged to: A. participate in strenuous exercises so that the tone of smooth muscle in the urinary tract can be strengthened to help propel calculi B. Limit their voiding to every 6 to 8 hours so that increased volume can increase hydrostatic pressure, which will help push stones along the urinary system. C. Increase their fluid intake so that they can excrete up to 4 liters every day. D. Supplement their diet with calcium needed to replace losses to renal calculi.

C; increase their fluid intake so that they can excrete up to 4 liters every day

what is a characteristic of the intrarenal category of acute kidney injury? A. decreased creatinine B. decreased urine sodium C. increased BUN D. high specific gravity

C; increased BUN

a nurse is assessing a client who was admitted to the facility for observation following a closed head injury. which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? A. vital signs B. body posture C. level of consciousness D. examination of pupils

C; level of consciousness

which is the most common cause of spinal cord injury? A. falls B. sports-related injuries C. motor vehicle crashes D. acts of violence

C; motor vehicle crashes

a client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. when documenting the experience, which medical terminology would the nurse be most correct to report? A. herniation B. paralysis C. paresthesia D. sciatic nerve pain

C; paresthesia

a client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms? A. potassium level of 2.9 B. blood glucose level of 60 C. sodium level of 150 D. phosphate level of 5.0

C; sodium level of 150

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? A. wound irrigation B. vitamin supplements C. surgical debridement D. wound packing

C; surgical debridement

the nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. what assessment finding does the nurse anticipate? A. the client has ecchymosis in the periorbital region B. the client has an elevated temperature C. the client has cerebral spinal fluid leaking from the ear D. the client has serous drainage from the nose

C; the client has cerebral spinal fluid leaking from the ear

which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis in a client with diabetes? A. the client continues medication therapy despite adequate food intake B. the client has not consumed sufficient calories C. the client has eaten and has not taken or received insulin D. the client has been exercising more than usual

C; the client has eaten and has not taken or received insulin

a nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. which of the following statements indicates that the client understands the procedure? A. "Ill drink less water so I don't have to catheterize myself too often" B. "I must use sterile technique for each of the catheterizations" C. "I should stop the catheterization when I removed 150 mL of urine" D. "I will perform intermittent self-catheterization every 2 to 3 hr"

D; "I will perform intermittent self-catheterization every 2 to 3 hr"

a nurse is teaching a client recovering from diabetic ketoacidosis about management of "sick days". the client asks the nurse why it is important to monitor the urine for ketones. which statement is the nurse's best response? A. "when the body does not have enough insulin, hyperglycemia occurs. excess glucose is broken down by the liver, causing acidic by-products to be released" B. "Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood." C. "Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid." D. "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

D; "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

a nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopression. which of the following information should the nurse include? A. "Drink at least 3 liters of fluid per day" B. "weigh yourself weekly while wearing similar clothing at the same time of day" C. "notify the provider of a weight loss of 1 pound or more per week" D. "report nocturia because it requires a dosage adjustment"

D; "report nocturia because it requires a dosage adjustment"

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? A. temporal skull fracture B. occipital skull fracture C. frontal skull fracture D. basilar skull fracture

D; basilar skull fracture

a nurse is assessing a client with possible Cushing's syndrome. in a client with Cushing's syndrome, the nurse expects to find: A. thick, coarse skin B. weight gain in arms and legs C. hypotension D. deposits of adipose tissue in the trunk and dorsocervical area

D; deposits of adipose tissue in the trunk and dorsocervical area

a client sustained a head injury when falling from a ladder. while in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. the client states feeling weak and having experienced an 8-pound weight loss since admission. what condition does the nurse expect the client to be tested for? A. pituitary tumor B. hypothyroidism C. syndrome of inappropriate antidiuretic hormone secretion D. diabetes insipidus

D; diabetes insipidus

which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure? A. dysrhythmia B. hypovolemia C. ureteral calculus D. glomerulonephritis

D; glomerulonephritis

the nurse is caring for a client with increased ICP after surgical resection of a brain tumor. the nurse recognizes the client is demonstrating late signs of ICP when which sign is observed? A. tachycardia B. hypotension C. low pulse pressure D. irregular respirations

D; irregular respirations

a patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2 F. a family member informs the nurse that the patient has not taken thyroid medication in over 2 months. what does the nurse suspect that these findings indicate? A. thyroid storm B. diabetes insipidus C. syndrome of inappropriate antidiuretic hormone D. myxedema coma

D; myxedema coma

which of the following would the nurse need to be alert for in a client with severe hypothyroidism? A. thyroid storm B. Addison's disease C. acromegaly D. myxedemic coma

D; myxedmic coma

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? A. positive Romberg sign B. negative Brudzinski's sign C. hyper-alertness D. positive Kernig's sign

D; positive Kernig's sign

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client? A. corneal abrasions B. retinal detachment C. glaucoma D. pressure on the optic nerve

D; pressure on the optic nerve

a female client is being successfully treated for Cushing's syndrome. the nurse should expect a decline in: A. menstrual flow B. hair loss C. bone mineralization D. serum glucose level

D; serum glucose level

a client diagnosed with acute kidney injury has a serum potassium level of 6.5 mEq/L. the nurse anticipates administering: A. sorbitol B. IV dextrose 50% C. calcium supplements D. sodium polystyrene sulfonate

D; sodium polystyrene sulfonate

which of the following is not a manifestation of Cushing's triad? A. widening pulse pressure B. irregular respiration C. hypertension D. tachycardia

D; tachycardia

the nurse is caring for a client who is experiencing increased intracranial pressure, resulting from a pituitary adenoma. the nurse should anticipate which intervention will likely be prescribed to help decrease this client's ICP? A. remaining in a side-lying position B. salvage therapy C. anticonvulsant agents D. transsphenoidal surgery

D; transsphenoidal surgery

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? A. bedrest at home for 72 hours B. no treatment unless the roommate begins to show symptoms C. admission to the nearest hospital for observation D. treatment with antimicrobial prophylaxis as soon as possible

D; treatment with antimicrobial prophylaxis as soon as possible

a patient has been diagnosed with meningococcal meningitis at a community living home. when should prophylactic therapy begin for those who have had close contact with the patient? A. within 72 hours after exposure B. within 48 hours after exposure C. therapy is not necessary prophylactically and should only be used if the person develops symptoms. D. within 24 hours after exposure

D; within 24 hours after exposure