FINAL

After the nurse determines that a patient has the following risk factors for melanoma, which risk factor should be the focus of patient teaching related to prevention? A. The patient is fair-skinned and has blue eyes. B. The patient has multiple dysplastic nevi. C. The patient's mother died of a malignant melanoma. D. The patient uses a tanning booth throughout the winter.

Answer C Although all A, B, and D have rationales for patient education; C has the highest risk factor for having melanoma in the future because of the genetic component. Answer C would be the priority.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition? A. Glycosuria B. Diaphoresis C. Weight loss D. Hypertension

Answer D Rationale: Hypertension is the major symptom associated with pheochromocytoma. Glycosuria, weight loss, and diaphoresis also are clinical manifestations of pheochromocytoma; however, they are not major symptoms.

The nurse is caring for a patient with pheochromocytoma who is scheduled for an adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? A. Vital signs B. I&O C. BUN results D. Urine for glucose and ketones

Answer: A Rationale: Severe hypertension is a hallmark expression of pheochromocytoma, and early detection can help prevent complications. Frequent measurement of vital signs can aid in early detection.

A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which items would be the most appropriate choice for this client to meet nutritional needs? A. Crackers with cheese and tea B. Graham crackers and warm milk C. Toast with peanut butter and cocoa D. Vanilla wafers and coffee with cream and sugar

Answer: B Rationale: The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals, and calories. Foods or beverages that contain caffeine, such as cocoa, coffee, tea, or colas are prohibited because they can precipitate a hypertensive crisis.

When teaching about infection prevention to a client with a long-term venous catheter, the nurse determines that teaching has been effective when the client states which of the following? A. "I will not remove the dressing until I return to the clinic next week." B. "My husband or I will do the dressing changes three times per week, exactly the way you showed us." C. "I will monitor my temperature once each weekday." D. "I know it is very important to wash my hands after irrigating the catheter."

Answer: B Rationale: The most important intervention for infection control is to continue meticulous catheter site care. Dressings are to be changed 2-3 times/week, depending on institutional policies. Temperature should be monitored at least once a day in someone with a VAD. Hand washing before and after irrigation or any manipulation of the site is a must for infection prevention.

A client with cancer has anorexia and weight loss. Which intervention should a nurse perform first? A. Give TPN through a central line. B. Start liquid nutrition through a gastric port. C. Start liquid nutrition through a duodenal port. D. Administer megestrol and a diet of choice with nutritional supplements.

Answer: D Rationale: D is correct, because malnutrition in cancer patients is complicated and often difficult to manage. While megestrol stimulates appetite, nutritional supplements provides nutrients. A is incorrect, because TPN may be necessary, but it is not the first strategy to try. The GI system should be used for nutrition when it is functional. B is incorrect, because light nutrition through a feeding tube may be necessary, but it is not the first strategy to try in a patient who is able to swallow. C is incorrect, because, although administration of enteral feedings via a tube is a reasonable strategy to manage malnutrition, less invasive strategies should be tried first.

A patient with MS is being taught self-care measures to prevent constipation. The nurse would realize that the teaching was effective when the patient states that they will avoid: a) Citrus fruits b) Laxatives c) Stool softeners d) High-fiber diet

B - Rationale: The patient should avoid laxatives and enemas because they can lead to dependence. The other choices are useful to maintaining good stool consistency.

The client with longstanding MG is admitted to the acute care unit after having been diagnosed and treated for cholinergic crisis. Which of the following warning signs of cholinergic crisis will the nurse teach the family? a) Restlessness b) Vertigo c) Tachycardia d) Tachypnea

B - Rationale: The usual cause of cholinergic crisis is overmedication while the cause of myasthenic crisis is undermedication. Manifestations of cholinergic crisis include GI manifestations, severe muscle weakness, vertigo, and resp distress

Cholelithiasis is always the cause of cholecystitis. A) True B) False

B) False Cholecystitis can occur without cholelithiasis

The patient has vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to the nurse, other patients, staff, and those outside the hospital? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions

B. Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact. Droplet precautions are used with pathogens that are spread through the air at close contact and that affect the respiratory system or mucous membranes (e.g., influenza, pertussis). Airborne precautions are used if the organism can cause infection over long distances when suspended in the air (e.g., TB, rubella). Standard precautions are used with all patients and included in the transmission-based precautions above.

Which nursing intervention is aimed at reducing muscle weakness in the client with MG? a) Taking medications as prescribed b) Performing passive ROM c) Assisting the client with ADLs d) Eating high protein, low carb diet

C - Rationale: Hallmark of MG is muscle weakness that increases with fatigue. If the nurse provides assistance with ADLs then it helps to prevent fatigue. Passive ROM will have no benefit on pt. Medications as prescribed will help maintain therapeutic blood levels. High protein, low carb is a way to lose weight and not build muscle

Which physical assessment finding does the nurse expect to observe in a client with myasthenia gravis? a) Unstable mood b) Bowel and bladder incontinence c) Difficulty or inability to perform the six cardinal positions of gaze d) Painful sensations

C - Rationale: early in the course of MG the muscles that control the eyes and eyelids are affected and this occurs in 90% of people with MG. Unstable mood, bowel and bladder incontinence, and painful sensations are all clinical manifestations of MS.

The nurse instructs her patient to ingest their pancreatic enzymes: A) once a day in the morning B) once a day before bed C) with each meal D) with the first meal of the day

C- Pancreatic enzymes are used to help the body absorb the nutrients of the food. They should be taken along with every meal.

Which of the following is a key component of cultural competence? a. No need for cultural knowledge b. Indifference to differences c. Awareness of one's own cultural values d. No need to understand the dynamics of difference

C. Cultural competence is a set of practice skills, knowledge, and attitudes that must encompass these elements: Awareness and acceptance of differences Awareness of one's own cultural values Understanding of the dynamics of difference Development of cultural knowledge Ability to adapt practice skills to fit the cultural context of the client or patient

The client with first relapse of MS is admitted to the acute care unit and the nurse prepares the clients plan of care with a priority given to: a) Urinary retention b) Paralysis of lower extremities c) Difficulty swallowing d) Visual deficits

D - Rationale: Clients with MS demonstrate visual deficits with onset and relapse of disease. They may also demonstrate spastic paresis, ataxia, and bladder urgencies, hesitancies, and incontinence. Weakness and numbness in one or both legs is common.

A client presents with an acute exacerbation of MS. Which drug will the nurse be prepared to administer? a) Zithromax b) Ascorbic Acid c) Interferon d) Methylprednisolone

D - Rationale: Methylprednisolone is the drug of choice for acute exacerbations. Zithromax treats advanced HIV infections. Ascorbic Acid is for patients who have a deficiency. Interferon beta-1a (avonex) helps decrease the number and severity of relapses in MS. Lewis Table 59-15 p. 1430

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that: A. Shock-wave therapy should be tried initially. B. Once gallstones are removed, they tend not to recur. C. The disorder can be successfully treated with oral bile salts that dissolve gallstones. D. Laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

D) Laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

A patient with acute pancreatitis is experiencing pain. The nurse would like to help the client with a position change. What two positions would help this patient? a) Fetal position b) Supine c) Reverse Trendelenburg d) Leaning forward e) Right lateral recumbent

b) A,D Rationale: Pain may be relieved by leaning forward or assuming the fetal position.

Combined with clinical manifestations, the laboratory finding that is most commonly used to diagnose acute pancreatitis is a) Increased serum calcium. b) Increased serum amylase. c) Increased urinary amylase. d) Decreased serum glucose.

b) B- Although serum lipase levels and urinary amylase levels are increased, an increased serum amylase level is the criterion most commonly used to diagnose acute pancreatitis. Serum calcium levels are decreased.

During the assessment of a patient with acute pancreatitis, the nurse notes a decrease in breath sounds bilaterally in the lung bases. What should the nurse do with this information? a) Document the finding b) Encourage the patient to use their incentive spirometer c) Contact the physician d) Increase the patient's IV fluids

b) C Rationale: Atelectasis may result from decreased diaphragmatic excursion because of abdominal distention or from direct injury from exposure to pancreatic enzymes

These are the interrelated constructs for the process of cultural competence: (Select All That Apply) • a. Self-awareness • b. Cultural knowledge • c. Cultural skill • d. Cultural attitude • e. Cultural desire • f. Cultural framework

• A, B, C, E - Giddens pg. 34

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? a) Vigilant infection control and adherence to standard precautions b) Careful monitoring of neurologic assessment and frequent reorientation c) Maintenance of a calorie count and hourly assessment of intake and output d) Assessment of blood pressure and monitoring for signs of orthostatic hypotension

A - Rationale: Infection control is a priority in the care of patients with MS, since infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit. Lewis Ch 59

Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? a) Activity intolerance b) Acute confusion c) Bowel incontinence d) Disturbed sleep pattern

A - Rationale: The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.

Wearable Cardioverter Defibrillators are Appropriate for (select all that apply) A. Patients with a left ventricular ejection fraction <35% waiting for ICD implantation B. Hospitalized patients who are waiting to have an ICD implanted C. Patients who don't meet ICD implantation criteria D. Patients who meet ICD implantation criteria but whose condition delays or prohibits implantation E. Stroke patients with a left ventricular ejection fraction <35% F. Patients who have undergone ICD removal, usually due to infection, and are waiting to have another ICD implanted

A, C, D, F

The ambulatory care nurse is discussing pre-op procedures with a Vietnamese American client who is scheduled for surgery the following week. During the discussion, the client continuously nods and smiles. How should the nurse interpret this behavior? a. Reflecting a cultural value b. An acceptance of the treatment c. Client agreement to the speaker d. Client understanding of the pre-op procedures

A. Nodding or smiling by an Asian American client may reflect only the cultural value of the interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure

A client has been diagnosed with pheochromocytoma. The nurse plans care, knowing that the client will exhibit which effect based on the pathophysiology of this disorder? A. Water loss B. Bradycardia C. Hypertension D. Decreased cardiac output

Answer: C Rationale: The client with pheochromocytoma has a benign or malignant tumor in the adrenal medulla. Because the medulla secretes epinephrine and norepinephrine, the client will exhibit signs related to excesses of these catecholamines, including tachycardia, increased cardiac output, and increased blood pressure. Vasoconstriction of the renal arteries triggers the renin-angiotensin system, resulting in water reabsorption and retention.

According to the IOM, safety is: A. The freedom from being written up for med errors B. Protection from being offended by coworkers C. The freedom from accidental injury D. All of the above

C

True or false, ingestible sensor systems have only been approved for use in humans to monitor medication adherence

False

What is needed in order for Telehealth to be successful? A. Complex system that ensures the most accurate information is obtained and assessed B. Compatible with patients everyday life C. Patients ability to speak English D. Patients ability to access a wireless device

b

When assessing the patient's pain level, the nurse concludes the patient is experiencing acute pancreatitis. What did the nurse assess? Select all that apply. a) Pain is decreased with leaning forward b) Pain is sharp like a knife, and occurs without warning c) Pain is relieved with passing flatus d) Pain is relieved with coughing e) Pain settles in the right shoulder f) Over-the-counter pain medications relieve the pain

b) A,B Rationale: Pain is a high-priority assessment. Characteristics of pain include sudden onset, sharp knifelike pain, twisting, deep, with radiation to the flank, chest, and abdomen. Pain may be relieved by leaning forward or assuming the fetal position.

What is the longitudinal electronic record of patient heath information produced by encounters in one or more care settings called? A. Electronic patient data B. Patient record C. Longitudinal record D. Electronic health record

d

Put these Ebola PPE steps in the correct order: 1. Put on boot covers 2. Put on respirator or PAPR 3. Put on gown - this needs to allow full range of motion 4. Remove all personal clothing and items 5. Put on outer apron 6. Put on outer gloves 7. Inspect PPE for integrity prior to donning

4. Remove all personal clothing and items 7. Inspect PPE for integrity prior to donning 1. Put on boot covers 3. Put on gown - this needs to allow full range of motion 6. Put on outer gloves 2. Put on respirator or PAPR 5. Put on outer apron

The nurse reinforces teaching for a patient after a cholecystectomy on a low fat diet. The nurse will know that the patient understands the diet if which of the following menu items is selected? A) skinless roasted chicken, rice, gelatin dessert B) cream of chicken soup, milk, gelatin dessert C) meat loaf, mashed potatoes with small amount of gravy, green beans D) turkey and cheese sandwich on whole grain bread, apple, and milk

A) skinless roasted chicken, rice, gelatin dessert These are low fat choices

An advance directive is written and notarized according to law in the state of New Mexico. This document is legal and binding: A. internationally. B. in the state of New Mexico only. C. in the continental United States. D. in the county of origination only.

(B) Choices A, C, and D are incorrect; advance directive protocols and documents are defined by each state.

In the relationship between DNR orders and advance directives (AD), all of the following are true except: A. an AD may help a physician decide whether a DNR order is the "right" decision for a particular patient. B. it can be assumed that a patient with an AD is a DNR. C. an AD is not necessary in order for a physician to write a DNR order (with the exception of New York State). D. a hospital-based DNR order should not require the patient's or family's signature but does require the physician's signature.

(B) It is NOT a correct assumption that a patient with an AD is a DNR.

As the nurse caring for Mrs. P, you discover during her admission assessment that she does not have advance directives. She asks whether there are any specific rules about naming a Durable Power of Attorney for Healthcare (DPOAHC) or document requirements. You accurately answer: A. "A person designated DPOAHC must be a family member." B. "A DPOAHC must be a lawyer." C. "The DPAOHC document must include the name, address, and contact information of the party named." D. "The individual named as DPOAHC must agree with the designee's decisions."

(C) The document records contact information of the party named. A person named as a DPOAHC can be anyone of choice. That person does not have to be any personal or professional relation. The DPOAHC does not have to agree with the designee's decisions but be willing and able to speak for them should decisions regarding care be needed

The authority conveyed to a Power of Attorney is revocable by: A. a primary care physician. B. a court proceeding. C. the family if all members agree. D. the person who originally delegated the authority following proper documentation procedures

(D) Only the person who delegates authority has the legal right to revoke the authority.

Which of these may be a warning sign of melanoma? A. A mole that's growing B. A mole that's itching or bleeding C. Varied colors in a mole D. All of the above

Answer: D Rationale: Any mole that is not round, has irregular edges or different colors, looks different from your other moles, is growing, or is itching, painful, or bleeding should be checked by a doctor right away.

A client is admitted with myasthenia gravis (MG). During the admission assessment, the nurse identifies that the client's upper eyelids are drooping. Which term should the nurse document to describe this assessment finding? a) Ptosis. b) Myopia. c) Keratitis. d) Astigmatism.

A - Rationale: Ptosis (A), a hallmark finding in MG, describes drooping of the eyelids associated with neuromuscular disorders, such as MG, a chronic disease from an autoimmune response that destroys acetylcholine receptors and affects the neuromuscular junction. (B, C, and D) are diagnostic and not descriptive terms used in documenting assessment findings. Myopia (B) is nearsightedness. Keratitis (C) is inflammation of the cornea. Astigmatism (D) is a refractive condition. From HESI comprehensive Exam 3

A client with MG develops a sudden increase in weakness, accompanied by an increase in heart rate from 76-100 bpm and an increase in blood pressure from 122/72 to 152/82 mmHg. Which conclusion will the nurse reach from these findings? a) The patient is experiencing myasthenic crisis b) The patient has orthostatic hypotension c) The patient is overweight d) The patient drank too much alcohol

A - Rationale: myasthenic crisis is characterized by an increase in muscle weakness and a rise in heart rate and blood pressure. With orthostatic hypotension the BP would decrease by 10 or 20 mmHg upon standing. Although being overweight and drinking alcohol can cause a higher blood pressure it is not the reason for the sudden increase

A living will includes which of the following:? Select all that apply. A. Documentation requirements B. How and when the living will takes effect C. How the patient's valuables are distributed among the family D. Immunity from liability for following the living will E. Which family member will inherit the person's home

A, B and D - The living will includes what circumstances are needed for the living will to be executed, documentation requirements, health care worker immunity from liability and witness requirements. Distribution of the patient's possessions is not included.

OSHA requirements for PPE include (select all that apply): A. PPE must be available in appropriate sizes B. PPE must be worn only in patient rooms C. Contact precautions must be used for every patient contact as part of standard precautions D. PPE must be readily available or issued to workers E. PPE must be properly disposed of or cleaned

A, D, E Not B (patients w/ precautions must wear masks in hallways, PPE is worn in OR), Not C

The nurse fills out an incident report after a patient received the wrong blood transfusion. What else should the nurse do? Select all that apply. A. Document a description of the incident itself in the patient's chart. B. Document in the patient's record that an incident report was completed. C. Make a copy of the incident report for the patient's chart. D. Stabilize the patient. E. Submit the incident report to the risk management department per policy. F. Withhold the incident report from the patient's medical record.

A, E, F - The incident report is an internal document for the the hospital and should not be mentioned in the medical record, nor should a copy be made for the patient's record. Only a factual description of the incident and any actions taken are documented in the patient's chart. The incident report is for the institution's own records to help improve policies and procedures via risk management. The patient should already be stable before the nurse fills out an incident report.

A patient is admitted with acute pancreatitis. What will the nurse expect to find upon assessment of this patient? Select all that apply. a. Brown, foamy urine b. Elevated blood pressure c. Diarrhea d. Hyperactive bowel sounds e. Heart rate 72 and regular f. Constipation

A,C Rationale: Brown, foamy urine is caused by bile being excreted through the kidneys. Diarrhea is a common finding in acute pancreatitis.

A patient is admitted to rule out acute pancreatitis. Which of the following laboratory tests will provide the most accurate information to support this medical diagnosis? a. Serum lipase b. Serum sodium c. Serum amylase d. Serum potassium

A- Rationale: The most commonly measured pancreatic enzymes are serum amylase and lipase. Measuring lipase levels provides a longer period for trending values than that provided by serum amylase levels.

The patient with acute pancreatitis starts to exhibit carpal spasms. The nurse suspects the patient to have: A) low calcium levels B) high calcium levels C) low magnesium levels D) high magnesium levels

A- The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign.

The nurse reminds the staff that standard precautions should be used when providing care for which type of patient? A. All patients regardless of diagnosis B. Pediatric and gerontologic patients C. Patients who are immunocompromised D. Patients with a history of infectious diseases

A. Standard precautions are designed for all care of all patients in hospitals and health care facilities.

A Mexican client goes to the hospital with her 8-year-old daughter. The client cannot speak English, and the 8-year-old child is attempting to translate the nurse's requests. How can the nurse aid communication between the non-English-speaking client and herself? a. The nurse should call the translating services department to get someone on staff to translate the information directly for the client. b. The nurse should ignore the client, explain the information in English to the client's 8-year-old daughter, and discharge the client. c. The nurse should let the child continue translating even though the nurse will never know if the correct information was communicated. d. The nurse should write down the information for the client in English and ask the client's 8-year-old daughter to go home and explain it to her mother in Spanish.

A. Whenever possible, family members (especially children) should not be used to interpret medical information. Although they may have better English skills, they may be too emotionally involved to give clear information. They may not have the language skills to ensure a clear understanding of the procedures to which the client is consenting. Also, including a family member in discussions can violate confidentiality. Newly instituted Health Insurance Portability and Accountability Act (HIPAA) regulations prevent information from being given to a family member without specific permission from the client. The hospital or health care institution must make provisions for maintaining privacy. (See more about HIPPA in Chapter 3.)Many health care facilities designate qualified employees to provide translation services. Each unit will have contact information for these individuals. Frequently these staff members are compensated for their skill. Nurses who have the ability to speak, write, or translate another language should provide that information to the human resources department.

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? A. Hypotension and fever B. Mental status changes and hypertension C. Subnormal temperature and hypotension D. Complaints of weakness and hypertension

Answer A Rationale: The nurse should be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. Options b, c, and d are incorrect options.

The nurse has just assisted a client back to bed after a fall. The nurse and provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? A. Reassess the client. B. Conduct a staff meeting to describe the fall. C. Document in the nurse's notes that an incident report was completed. D. Contact the nursing supervisor to update information regarding the fall.

Answer A: After a fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private info and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

While the nurse is administering medication, the client says, "This pill looks different from what I usually take." What is the nurse's best action? A. Go recheck the medication order, taking along the medication B. Ignore the statement because the client has a history of confusion C. Leave the medication at the bedside and go recheck the order D. Tell the client that pill manufacturers often change the color of pills

Answer A: Go recheck the medication order, taking along the medication. This is a safety issue and should not be ignored. Leaving the medication at the bedside is an unsafe practice and does not demonstrate the nurse's responsibility. If checking the medication order does not clarify the situation, then the nurse should check with the pharmacist regarding pill shape, color, and so on. Different manufacturers will design their own brands to look different from their competitors' brands. Checking the client's statement can avoid a potential medication error, and the client appreciates the efforts of the nurse.

Melanoma is definitively diagnosed by: A. Visual examination and assessment B. Chest x-ray C. Skin biopsy D. All of the above

Answer C Rationale: Biopsy is the definitive diagnosis of melanoma

A client is brought to the ED by EMS after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure. B. Ask the EMS team to sign the informed consent. C. Transport the victim to the OR for surgery. D. Call the police to identify the client and locate the family.

Answer C: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death. The second is when the client waives the right to give informed consent.

When identifying a new client before administering medications, the nurse asks the client to state his name. The client does not give the correct name. The nurse asks again and the client states still another name. What is the nurse's next action? A. Laugh at the client and tell him to "quit kidding." B. Give the medications without any further questioning. C. Investigate the client's mental status before administering any further medications. D. Look at the client's arm band to identify the client and disregard what the client said.

Answer C: Investigate the client's mental status before administering any further medications. The ongoing physical and mental status of a client affects whether a medication is given or how it is administered. The client should be assessed carefully before administering any medication. The nurse should always check the client's arm band to ensure that this is the correct client for the given medication, even if the client responds with the correct name. The client should always be identified using at least two identifiers before administering medication, preferably by comparing the client identifiers on the MAR with the client's arm band at the bedside.

A 45-year-old obese woman was admitted with a medical diagnosis of cholecystitis. The nurse assigned to her care would expect her present illness to include intolerance to which nutrient? A) Carbohydrates B) Medium Chain Triglycerides C) Albumin D) Ascorbic Acid

B) Medium Chain Triglycerides Inflammation of the gallbladder, presence of gallstones, or both interfere with movement of the bile from the liver or gallbladder into the small intestine, where it promotes the digestion of fats

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? A. The client fell out of bed. B. The client climbed over the side rail. C. The client was found lying on the floor. D. The client became restless and tried to get out of bed.

Answer C: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse.

When assessing a lesion diagnosed as a malignant melanoma, the nurse most likely expects to note which finding? A. Irregularly shaped lesion B. A small papule with dry, rough scaling C. A firm, nodular lesion topped with crust D. A pearly papule with a central crater and a waxy border

Answer: A Rationale: A melanoma is an irregularly shaped papule or plaque with red, white, or blue-toned color. Actinic Keratosis - premalignant lesion appears as a small macule/papule with a dry, rough, adherent yellow/brown scale. Squamous Cell Carcinoma - a firm nodule lesion, topped with crust or a central area of ulceration. Basal Cell Carcinoma - appears as a pearly papule with a central crater and rolled, waxy border.

The health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The community health nurse visits the client at home and instructs the client in the procedure for the collection of the urine. Which statement, if made by the client, would indicate a need for further instruction? A. "I can take medication if I need to during the collection. " B. "When I start the collection, I will urinate and discard that specimen. " C. "I will pour the urine in the collection bottle each time I urinate and refrigerate the urine. " D. "I will start the collection in 2 days. Starting now, I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed."

Answer: A Rationale: Clients are reminded not to take medications for 2 to 3 days before a 24-hour urine collection for vanillylmandelic acid (VMA). Because a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore the client is instructed to void, discard the first urine, note the time, and start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. For a VMA determination, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins.

A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset, because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that: A. Some melanomas have a familial component, and she should seek medical advice. B. Her personal risk is low, because most melanomas occur at age 60 or older. C. Her personal risk is low, because melanoma does not have a familial component. D. She should not worry, because she did not experience severe sunburn as a child

Answer: A Rationale: Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age group. Severe sunburn as a child does increase the risk; however, this client is at increased risk because of her family history.

The correct nursing actions when administering a vesicant chemotherapeutic agent are: (Select all that apply) A. Assess the site for swelling, redness, or presence of vesicles. B. Administer the drug by IV push. C. Give the drug slowly to minimize cardiac toxicity. D. Apply ice to the site if infiltration occurs. E. Apply heat to the site if extravasation occurs

Answer: A, E Rationale: A is correct, because these are local signs of tissue damage from infiltration of a vesicant, which causes blistering or necrosis with infiltration. E is correct, because heat is specifically recommended to prevent ulceration with vincristine or vinblastine if extravasation of the drug occurs. B is incorrect, because IV push would increase the chance of infiltration. Non-vesicants, which may cause little to no irritation if infiltration occurs, can safely be given IV push. C is incorrect, because not all vesicants are cardiotoxic. D is incorrect, because ice or a cold pack should not be used with vinca alkaloids.

Which intervention would most likely prevent nausea in a client receiving chemotherapy? A. Administering trimethobenzamide PRN nausea. B. Administering dexamethasone and ondansetron prior to chemotherapy. C. Serving all food warm or hot. D. Keeping client NPO for 24 hours prior to chemotherapy

Answer: B Rationale: B is correct, because there is often specific matching of nausea treatments and chemotherapeutic agents. Nausea is better prevented than treated, by giving the anti-emetic prior to administering chemotherapy.

The client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which statement is the appropriate response by the nurse? A. "I think you are making the right decision to have the surgery. " B. "You have concerns about the surgical treatment for your condition? " C. "You are very ill. Your health care provider has made the correct decision. " D. "There is no reason to worry. Your health care provider is a wonderful surgeon."

Answer: B Rationale: Paraphrasing is restating the client's messages in the nurse's own words. The correct option addresses the therapeutic communication technique of paraphrasing. Telling the client there is no reason to worry is offering a false reassurance, and this type of response will block communication. Telling the client that the health care provider has made the correct decision also represents a communication block in that it reflects lack of the client's right to an opinion. In the remaining option, the nurse is expressing approval, which can be harmful to the nurse-client relationship.

A nurse is performing an admission assessment on a client with a diagnosis of pheochromocytoma. The nurse should assess for the major sign associated with pheochromocytoma by performing which action? A. Obtaining the client's weight B. Taking the client's blood pressure C. Testing the client's urine for glucose D. Palpating the skin for its temperature

Answer: B Rationale: Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the major sign associated with pheochromocytoma. Taking the client's blood pressure would assess the blood pressure status. Weight loss, glycosuria, and diaphoresis are also clinical manifestations of pheochromocytoma, yet hypertension is the major sign.

Which of the following statements is most accurate regarding the long-term toxic effects of cancer treatments on the immune system? A. Clients with persistent immunologic abnormalities after treatment are at a much greater risk for infection than clients with a history of splenectomy. B. The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. C. Long-term immunologic effects have been studied only in clients with breast and lung cancer. D. The helper T-cells recover more rapidly than suppressor T-cells, which results in a positive helper cell balance that can last up to 5 years.

Answer: B Rationale: Studies of long-term immunologic effects in clients treated for leukemia, Hodgkin's disease, and breast cancer reveal that combination treatments of chemotherapy and radiation can cause overall bone marrow suppression, decreased leukocyte counts, and profound immunosuppression. Persistent and severe immunologic impairment may follow radiation and chemotherapy (especially multi-agent therapy). There is no evidence of greater risk of infection in clients with persistent immunologic abnormalities. Suppressor T-cells recover more rapidly than the helper T-cells

Cancer prevalence is defined as: A. The likelihood cancer will occur in a lifetime B. The number of persons with cancer at a given point in time C. The number of new cancers in a year D. All cancer cases > 5 years old

Answer: B Rationale: The word prevalence in a statistical setting is defined as the number of cases of a disease present in a specified population at a given time.

The nurse is caring for a postoperative client who has had an adrenalectomy. What should the nurse check for in the client's focused assessment? A. Peripheral edema B. Bilateral exophthalmos C. Signs and symptoms of hypovolemia D. Signs and symptoms of hypocalcemia

Answer: C Rationale: Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. Thus, a deficiency can cause hypovolemia. A deficiency of adrenocortical hormones (such as after adrenalectomy) does not cause the clinical manifestations noted in options A, B, and D.

A client is admitted to the hospital with a diagnosis of pheochromocytoma. The nurse would check which item to detect the primary manifestation of this disorder? A. Weight B. Urine ketones C. Blood pressure D. Skin temperature

Answer: C Rationale: Hypertension is the major symptom associated with pheochromocytoma and is assessed by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the major symptom.

A patient returns to the clinic for follow-up treatment s/p skin biopsy of a suspicious lesion performed a week ago. The biopsy report indicates the lesion is a melanoma. The nurse understands that a melanoma has which characteristic? A. Metastasis is rare. B. A melanoma is encapsulated. C. A melanoma is highly metastatic. D. A melanoma is characterized by localized invasion.

Answer: C Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis/treatment. Melanoma is highly metastatic to the brain, lungs, bone, and liver with survival depending on early diagnosis and treatment. A, B, and D are not characteristics of melanoma.

Which of the following groups would benefit most from education regarding potential risk factors for melanoma? A. Adults over age 35 B. Senior citizens who have been repeatedly exposed to the effects of UVA and UVB rays C. Parents with children D. Employees of a chemical factory

Answer: C Rationale: Sun damage is a cumulative process. Parents should be taught to apply sunscreen and teach their children to use sunscreen at an early age. Although preventative education is always valuable, serious sunburns in childhood are associated with an increased risk of melanoma. Adults and senior citizens have already been exposed to the harmful effects of the sun and, although they, too, should use sunscreen, they are not the group that will most benefit from the intervention. Exposure to chemicals is not a risk factor for melanoma.

A client undergoing chemotherapy has a WBC count of 2,300/mm3, Hgb of 9.8 g/dL, platelet count of 80,000/mm3, and K+ of 3.8. Which of the following should take priority? A. BP 136/88 B. Emesis of 90 mL C. Temperature 101 F (38.3 C) D. Urine output 40 mL/hour

Answer: C Rationale: The client has a low WBC count from the chemotherapy and has a temperature. S/S of infection may be diminished in a client receiving chemotherapy; therefore, the temperature elevation is significant. Early detection of the source of infection facilitates early intervention. Surveillance for bleeding is important with the low hemoglobin and platelet count; however, the high BP does not indicate bleeding. Vomiting is a SE of chemotherapy and should be treated. The urine output and potassium are WNL.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate? A. Apply sunscreen only after going into the water. B. Avoid peak exposure hours from 9am to 1pm. C. Wear loosely woven clothing for added ventilation. D. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.

Answer: D Rationale: A sunscreen with an SPF of 15 or higher should be worn on all sun-exposed skin surfaces. It should be applied before sun exposure and reapplied after being in the water. Peak sun exposure usually occurs between 11am-3pm. Tightly woven clothing, protective hats, and sunglasses are recommended to decrease sun exposure. Sun tanning parlors should be avoided.

In setting goals for a client with advanced cancer who has poor nutrition, the nurse determines that which of the following is a desired outcome for the client? The client will: A. Have normalized albumin levels. B. Return to ideal body weight. C. Gain 1 lb. every 2 weeks. D. Maintain current weight.

Answer: D Rationale: An appropriate and realistic outcome would be for the client to maintain current weight or not lose any weight. It is unrealistic to expect that the client with advanced cancer will have normal albumin levels or will be able to gain weight.

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A. A coagulation time of 5 minutes B. A urinary output of 50 mL/h C. A BUN of 20 mg/dL D. HR 90 bpm and irregular

Answer: D Rationale: An irregular heart rate indicates a dysrhythmia, which is a common manifestation of pheochromocytoma. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/h is an adequate output. A BUN of 20 is a normal finding

Which common systemic side effect of chemotherapy will a nurse note in an oncology client? A. Ascites B. Septicemia C. Polycythemia D. Leukopenia

Answer: D Rationale: D is correct, because chemotherapy causes myelosuppression (depression of bone marrow function). WBCs, RBCs, and platelets are decreased. A is incorrect, because ascites is the accumulation of fluid in the peritoneal space - this may occur as the result of a disease process, such as liver failure, but not from chemotherapy. B is incorrect, because septicemia is the presence of an infection in the blood. Chemotherapy may increase the client's risk for infection due to decreased WBCs, which, if not treated, could result in septicemia. C is incorrect, because polycythemia is an increase in immature RBCs. Chemotherapy suppresses RBC production in the bone marrow.

A client is scheduled to begin chemotherapy. A venous access device has been placed for administration of chemotherapeutic medications. Three days later at the client's scheduled appointment, the nurse assesses that the client is dyspneic and the skin is warm and pale. Vital signs are: HR 132, BP 80/30, RR 28, T 103 F, O2 84%. The central line insertion site is inflamed. After calling the rapid response team, what should the nurse do next? A. Place cold, wet compresses on the client's head. B. Obtain a portable ECG monitor. C. Administer a prescribed anti-pyretic. D. Insert a PIV and infuse NS.

Answer: D Rationale: D is correct, because the client is experiencing severe sepsis, and it is essential to increase circulating volume to restore the BP and CO. The wet compress, administering the anti-pyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time.

A client is admitted to a hospital in the terminal stage of illness. At this time, a nurse, who is planning end-of-life care, should recognize that the client is most likely to fear: A. The terminal diagnosis B. Further chemotherapy C. Being socially inadequate D. Dying alone and in pain

Answer: D Rationale: D is correct, because the client who is terminally ill most often wishes to be pain-free and to know that someone will be there in the end. A is incorrect, because the stem says that this is a terminal admission. Dealing with the diagnosis would not be the most common fear. B is incorrect, because a terminal admission generally means that the care will be palliative, not curative. C is incorrect, because the needs of the client at the time of a terminal admission are for palliation, not continuation of a normal lifestyle.

A hospitalized client is diagnosed with dysfunction of the adrenal medulla. The nurse monitors for changes in client status related to altered production and secretion of which substance? A. Cortisol B. Androgens C. Aldosterone D. Epinephrine

Answer: D Rationale: Epinephrine and norepinephrine are produced by the adrenal medulla. The other substances listed (cortisol, androgens, and aldosterone) are produced by the adrenal cortex.

A nurse is conducting a cancer risk screening program. Which of the following clients is at greatest risk for skin cancer? A. 45-year-old physician B. 15-year-old high school student C. 30-year-old butcher D. 60-year-old mountain biker

Answer: D Rationale: Melanoma commonly occurs in sun-exposed areas of the body. The incidence of skin cancer is also highest in older people who live in the mountains or spend outdoor leisure time at higher altitudes.

A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? A. Causes profound hypotension B. Is manifested by sever hypoglycemia C. Is not curable and is treated symptomatically D. Causes the release of excessive amounts of catecholamines.

Answer: D Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headache.

A nurse can best meet the needs of an individual with MS who is having a serious flare-up and receiving IV corticosteroids by: a) Reassuring the patient that neurologic deficits are always temporary b) Telling the patient that improvement may occur in 24-48 hours c) Assuring the patient that complete recovery will take no longer that 2 weeks d) Initiating a referral to a long-term care facility

B - Rationale: No definitive words in questions, no cure for MS, and no need to go to long-term care facility right now. Since patient is receiving meds, the symptoms should calm down because corticosteroids are used to treat flare-ups

The nurse formulates the nursing diagnosis of Impaired Physical Mobility related to muscle weakness for a patient with MS. Useful interventions the nurse could plan include: a) Encouraging long naps or rest periods b) Having the client perform ROM exercises at least 2 times daily c) Encouraging strengthening exercises for affected muscles every 4 hours d) Performing all ADLs for the patient

B - Rationale: ROM exercises should be performed at least 2 times per day. The rest of the interventions might cause excess fatigue or increased weakness.

A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with: a) Admission and administration of IV corticosteroids. b) An increased dose of anticholinesterase drugs. c) Bolus doses of atropine titrated to effect. d) Rest and increased sleep.

B - Rationale: With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug dose does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options are used to treat myasthenic

When a patient is receiving a Tensilon Test, what drug should be used to counteract the effects in case of an emergency? a) Flumazenil b) Atropine c) Naloxone d) Donepezil

B - Rationale: need an anticholinergic drug because will reverse Tensilon. It is an acetylcholinesterase inhibitor test so ACh levels will increase

A patient has acute pancreatitis due to a gallstone blocking a bile duct. Which diagnostic test would be the most useful to expedite the recovery of this patient. a. Pancreatic ultrasound b. ERCP c. Aspiration biopsy d. CT scan of the pancreas

B Rationale: ERCP provides the opportunity to remove mechanical obstructions such as a gallstone or pancreatic stone.

Teaching in relation to home management after a laparoscopic cholecystectomy should include: A. Keeping the bandages on the puncture sites for 48 hours. B. Reporting any bile-colored drainage or pus from any incision. C. Using over-the-counter anti-emetics if nausea and vomiting occur. D. Emptying and measuring the contents of the bile bag from the T tube every day.

B) Reporting any bile-colored drainage or pus from any incision. Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)? a) EEG b) CT scan c) Carotid duplex scan d) Evoked response testing e) Cerebrospinal fluid analysis

B, D, E Rationale: There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS. Lewis Ch 59

Who would be most at risk for developing gallstones? A. A male 20-year-old male who exercises regularly and eats fast food twice a week. B. A 50-year-old female who has a BMI of 32 and lives a sedentary lifestyle. C. A 25-year-old female who have never taken oral contraceptives. D. A 90-year-old male with an aunt who had gallstones.

B. A 50-year-old female who has a BMI of 32 and lives a sedentary lifestyle. The patient has the most concurrent risk factors.

A non-English speaking client enters the clinic and repeats the word "doctor." What can the nurse do to assist this client? a. Repeat the word "nurse" back to the client. b. Ask the doctor to come out to see the client. c. Tell the client to sign the sign-in sheet. d. Assist this client to a chair in the waiting room.

B. His question demonstrates that the nurse does not have enough cultural information to assist this client. The only real choice is for the nurse to find the doctor who might be better able to assist the client.

A patient with MS has a sudden worsening in vision and motor activity after being given a hot bath. What is this patient experiencing? a) MS relapse b) Medication side effects c) Uhthoff's sign d) Shock

C - Rationale: A transient temperature-dependent numbness, weakness, or loss of vision. Conduction stops in any nerve if the temperature becomes too elevated. In a damaged nerve, by demyelinization, this shutdown temperature is lowered, and may approach normal body temperature. Transient neurologic dysfunction may then appear with a hot shower, exercise, or fever.

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? a) A 42-year-old patient with multiple sclerosis who was admitted with sepsis b) A 72-year-old patient with Parkinson's disease who has aspiration pneumonia c) A 38-year-old patient with myasthenia gravis who declined prescribed medications d) A 45-year-old patient with amyotrophic lateral sclerosis who refuses enteral feedings

C - Rationale: Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop a myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest. Lewis Ch 59

The nurse can best enhance the patients self-efficacy by: a) Referring the patient to a psychologist b) Suggesting the patient avoid crowds c) Providing education and support d) Referring the patient to a social worker

C - Rationale: Providing education and support will increase the individuals belief in his/her own capacity to execute behaviors necessary to manage own care. Referral to psychologist and social worker might make the patient feel worse about themselves and its 'passing the puck'. Avoid crowds is to prevent infection and promotes social isolation.

A nurses is preparing a client newly diagnosed with MS for discharge home. The client has been prescribed cyclophosphamide and methylprednisolone. Which instruction will the nurse include in the teaching plan for the client? a) Wear sunscreen b) Dangle before standing c) Avoid people with colds d) Avoid grapefruit juice

C - Rationale: The client should be taught to avoid large groups and individuals with any type of upper respiratory illness because these medications are immunosuppressant's and there is an increased risk of infection

The nurse reminds a group of students about the major component of the pathophysiology in MS, which is: a) Damage occurs primarily to the dendrites and oligodendrites b) Once damaged, myelin cannot regenerate at all c) Plaques occur anywhere in the white matter of the CNS d) Schwann cells are destroyed slowly but relentlessly

C - although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord

The night before an elective surgery, a client asks the nurse why he was asked to complete an advance directive on admission. The nurse's best response is: A. "It's just a formality." B. "This form helps the care team understand your wishes so we won't be sued." C. "It is a legal requirement that all clients entering the hospital have the opportunity to express their wishes through an advance directive." D. "Are you worried that you might not live through your surgery?"

C) All patients entering the hospital for any reason are asked to complete advance directives according to JCAHO standards. The guiding ethical principle is patient autonomy, not liability protection for the healthcare providers.

A Spanish-speaking client needs educational materials about hepatitis. Which of the following would be the best action for the nurse to take to help this client? a. Decide the client does not really need this information. b. Provide the client with the instructions written in English. c. Contact an interpreter to read the printed English instructions to the client in Spanish. d. Tell the client that instructions do not exist for that health problem.

C. According to the National Standards for Culturally and Linguistically Appropriate Services in Healthcare, Standard 6 states that all clients with limited English proficiency (LEP) are to be provided access to bilingual staff or interpretation services. Since the instructions are not available written in Spanish, the next best thing is to ask an interpreter to read the English instructions to the client in Spanish.

• An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse he would like to take a herbal substance to help lower his blood pressure. The nurse should take which action? • a. Tell the client the herbal substances are not safe and should never be used • b. Teach the client how to take their blood pressure so it can be monitored closely • c. Encourage the client to discuss the use of an herbal substance with their HCP • d. Tell the client that if they take the herbal substance they will need to have their blood pressure checked frequently

C. Although herbal substance have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances with similar pharmalogical effects because the combo may lead to an excessive reaction or unknown interaction effects The nurse should advise the client to discuss the substance with their HCP

A nurse is caring for two clients, both of whom have had abdominal surgery. One, a Hispanic, writhes in pain and moans when touched, and the other, an Asian, appears calm and rarely complains of pain or discomfort. Which of the following statements regarding this situation is true? a. The Asian client is not experiencing pain. b. The Hispanic client is exhibiting drug-seeking behavior. c. Culture and ethnicity may affect how a client exhibits distress. d. The Hispanic client is exaggerating his pain.

C. Both have a direct effect on communication style, but the nurse should avoid stereotyping or false assumptions when planning and providing care. The presence or absence of pain must be validated by direct query. The nurse should never be judgmental of a client's behaviors. All complaints of pain by a patient must be believed and addressed.

What is the most common sign/symptom of gallstones? A. Choroidal Nevi B. Fatigue C. Pain D. Trousseau's sign

C. Pain Pain is commonly associated with gallstones, the other responses are not.

A Native American client with a low-grade fever insists on using a sweat lodge to treat his illness. What is the nurse's best response? a. Explaining to the client why the sweat lodge may exacerbate his fever b. Monitoring the client's condition, and keeping in mind that treatment consistent with the client's beliefs will probably be the most successful c. Asking the client's relatives to convince him not to use the sweat lodge d. Notifying the physician and asking her to intervene

C. The nurse's best response is to monitor the client's condition, and to keep in mind that treatment consistent with the client's beliefs probably will be the most successful. The client who doesn't believe in Western medicine will not believe the sweat lodge will worsen his condition. Asking the client's relatives to convince him not to use the sweat lodge would not promote good relations with the client and may violate his right to privacy. The nurse should attempt to find a solution before asking the physician to intervene.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggest that teach is most effective? a) Eating large, well-balanced meals b) Doing muscle strengthening exercises c) Doing all chores early in the day while less fatigued d) Taking medications in time to maintain therapeutic blood levels

D - Rationale: Taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Overeating is a cause of exacerbation of symptoms as is exposure to heat, crowds, erratic sleep habits, and emotional stress. Muscle strengthening activities can cause fatigue.

Immediately after undergoing a thymectomy, the nurse monitors for which complications in the client with myasthenia gravis? a) Absent peripheral pulses b) Hemiparesis c) Weight gain d) Sudden onset of shortness of breath

D - Rationale: the nurse must be alert for a pneumothorax or hemothorax which can manifest as shortness of breath. Absent peripheral pulses and hemiparesis are not complications of a thymectomy. Weight gain can be a side effect of the steroids required after a thymectomy

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? A) Right upper quadrant, radiating to the left scapula and shoulder B) Right lower quadrant, radiating to the back C) Right lower quadrant, radiating to the umbilicus D) Right upper quadrant, radiating to the right scapula and shoulder

D) Right upper quadrant, radiating to the right scapula and shoulder During an acute episode of cholecystitis, the patient may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body

The patient with chronic pancreatitis is more likely than the patient with acute pancreatitis to a) Need to abstain from alcohol. b) Experience acute abdominal pain. c) Have malabsorption and diabetes mellitus. d) Require a high-carbohydrate, high-protein, low-fat diet.

b) C- Chronic damage to the pancreas causes pancreatic exocrine and endocrine insufficiency, resulting in a deficiency of digestive enzymes and insulin. Malabsorption and diabetes often result. Abstinence from alcohol is necessary in both types of pancreatitis, as is a high-carbohydrate, high-protein, and low-fat diet. Although abdominal pain is a major manifestation of chronic pancreatitis, more commonly a heavy, gnawing feeling occurs.

The nurse determines that further discharge instruction is needed when the patient with acute pancreatitis states a) "I should observe for fat in my stools." b) "I must not use alcohol to prevent future attacks of pancreatitis." c) "I shouldn't eat salty foods or foods with high amounts of sodium." d) "I will need to continue to monitor my blood glucose levels until my pancreas is healed."

b) C- Sodium restriction is not indicated for patients recovering from acute pancreatitis, but the stools should be observed for steatorrhea, indicating that fat digestion is impaired, and glucose levels should also be monitored for indication of impaired B-cell function. Alcohol is a primary cause of pancreatitis and should not be used.