HCR522-Pathophys 2 | Combined TB1 (various)

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1. "A bone fragment has injured the nerve supply in the area." 2. "An injured artery caused impaired arterial perfusion through the compartment." 3. "Bleeding and swelling caused increased pressure in an area that couldn't expand." 4. "The fascia expanded with injury, causing pressure on underlying nerves and muscles."

"Bleeding and swelling caused increased pressure in an area that couldn't expand." Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? 1. "I can use the blunt part of a ruler to scratch the area." 2. "I can trickle small amounts of water down inside the cast." 3. "I need to obtain assistance when placing an object into the cast for the itching." 4. "I can use a hair dryer on the low setting and allow the cool air to blow into the cast."

"I can use a hair dryer on the low setting and allow the cool air to blow into the cast." Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin, thereby providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. "I need to cover the casted leg with warm blankets." 3. "I need to use my fingertips to lift and move my leg." 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

"I need to avoid getting the cast wet." A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? 1. "The bathroom has hand railings in the shower." 2. "There are three steps to get up to the front door." 3. "My family has rented a commode for me to use." 4. "My bedroom and bathroom are on the second floor of my home."

"My bedroom and bathroom are on the second floor of my home." Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails should be installed and the area kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.

The nurse is providing education to a client with type 2 diabetes mellitus. The nurse explains in layperson's language the physiological mechanism behind hypoglycemia. Which response by the client determines that teaching has been successful? 1. "My body cannot make insulin." 2. "My body has decreased epinephrine levels." 3. "My body decreases release of cortisol, which is a stress hormone." 4. "My body increases glucagon production to fight low blood sugars."

"My body increases glucagon production to fight low blood sugars." Glucagon is secreted from the alpha cells in the pancreas in response to declining blood glucose levels. At the same time, hypoglycemia triggers increased cortisol release, increased epinephrine release, and decreased secretion of insulin. Options 1, 2, and 3 are not physiological mechanisms that take place to combat the decrease in the blood glucose level.

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? 1. "Canes prevent falls; they do not cause them." 2. "The cane would help to break a fall, even if you do slip." 3. "The cane has a flared tip with concentric rings to give stability." 4. "The physical therapist will determine if the cane is inadequate."

"The cane has a flared tip with concentric rings to give stability." A cane should have a slightly flared tip with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. The remaining options are unrelated to the subject of providing reassurance regarding safety and do not provide the client with reassurance about his or her concern.

The nurse is caring for a client who has just returned from having a cystoscopy. The nurse should recognize which as an abnormal assessment finding for this client? 1. The nurse notes bright red urine output. 2. The nurse notes pink-tinged urine output. 3. The client reports having urinary frequency. 4. The client complains of burning when urinating.

1 (► The main purpose of a cystoscopy is to inspect the interior of the bladder with a tubular lighted scope (cystoscope). ► Pink-tinged urine is a normal finding after this procedure, but bright red urine indicates hemorrhaging and is not a normal finding. ► The remaining options are normal findings following this procedure.)

The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. 1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I can use crutch tips even when they are wet." 4. "I need to have spare crutches and tips available." 5. "When I'm using the crutches, my arms need to be completely straight."

1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 4. "I need to have spare crutches and tips available." The client should use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.

The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. 1. Fatigue 2. Weight gain 3. Restlessness 4. Morning stiffness 5. Pain with movement only

1. Fatigue 4. Morning stiffness Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply. 1. Irritability 2. Complaints of nausea 3. Sodium level of 128 mEq/L (128 mmol/L) 4. Potassium level of 3.2 mEq/L (3.2 mmol/L) 5. Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg

1. Irritability 2. Complaints of nausea 3. Sodium level of 128 mEq/L (128 mmol/L) 5. Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg Findings consistent with a diagnosis of adrenal insufficiency include nausea, vomiting, and diarrhea; hyponatremia; salt craving; hyperkalemia; and orthostatic hypotension. Irritability and depression may also occur in primary adrenal hypofunction.

The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items should the nurse recommend as being high in calcium? Select all that apply. 1. Tofu 2. Salmon 3. Peaches 4. Spinach 5. Sardines

1. Tofu 2. Salmon 4. Spinach 5. Sardines Foods high in calcium include milk and milk products, dark green leafy vegetables, tofu and other soy products, sardines, salmon with bones, and hard water. Options 1, 2, 4, and 5 are all foods that are high in calcium. Peaches are high in vitamins A and C.

The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. 1. Use night lights. 2. Remove scatter rugs. 3. Use staircase railings. 4. Remove wall-to-wall carpeting. 5. Place hand rails in the bathroom.

1. Use night lights. 2. Remove scatter rugs. 3. Use staircase railings. 5. Place hand rails in the bathroom. Home modifications to reduce the risk for falls include using railings on all staircases, providing ample lighting, removing scatter rugs, and placing hand rails in the bathroom. Removing wall-to-wall carpeting is not necessary as long as it is in good condition.

The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

a. 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).

The uterus is usually positioned tilting forward and superior to the bladder. This position is known as: a. Anteverted and anteflexed. b. Retroverted and anteflexed. c. Retroverted and retroflexed. d. Superiorverted and anteflexed.

a. Anteverted and anteflexed.

A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. 1. Use the overhead trapeze. 2. Keep the head of the bed flat. 3. Place pillows under the length of the legs. 4. Use logrolling technique for repositioning. 5. Assist the client with eating meals and drinking fluids.

2. Keep the head of the bed flat. 3. Place pillows under the length of the legs. 4. Use logrolling technique for repositioning. 5. Assist the client with eating meals and drinking fluids. After a client has spinal fusion, the head of bed generally is kept flat. Because the client is in the flat position, the nurse should assist the client with eating meals and drinking fluids. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs, in accordance with surgeon preference, to relieve tension on the lower back. The use of an overhead trapeze may decrease control of spinal movement and is contraindicated because its use could promote twisting of the spine after surgery.

The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion should the nurse anticipate? 1. 100 to 300 mL/min 2. 500 to 1000 mL/min 3. 1200 to 1500 mL/min 4. 2000 to 2500 mL/min

3 (► The kidneys normally receive about 20% to 25% of the cardiac output when the client is at rest. If the cardiac output is 6 L/min, the kidneys receive 1.2 to 1.5 L/min, which is equal to 1200 to 1500 mL/min.)

The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. 1. Elevated white blood cell count 2. A decreased sedimentation rate 3. Joint pain that diminishes after rest 4. Elevated antinuclear antibody levels 5. Joint pain that intensifies with activity

3. Joint pain that diminishes after rest 5. Joint pain that intensifies with activity The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.

The nurse is caring for an older client. Which finding should the nurse expect to note in this client while evaluating renal function? 1. Tubular reabsorption increases 2. Urine-concentrating ability increases 3. Medications are metabolized in larger amounts 4. The glomerular filtration rate (GFR) diminishes

4 (► As part of the normal aging process, the GFR decreases, along with each of the other functional abilities of the kidney. ► Tubular reabsorption and urine-concentrating ability also decrease. ► The kidneys have decreased ability to metabolize medications.)

The nurse is caring for a client with a bladder infection. The nurse plans care understanding that the primary risk factor for spread of infection in this client is dysfunction of which structure? 1. Urethra 2. Nephron 3. Glomerulus 4. Ureterovesical junction

4 (► The ureterovesical junction is the point at which the ureters enter the bladder. ► At this juncture, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. ► This anatomical pathway prevents reflux of urine back into the ureter and, in essence, acts as a valve to prevent urine from traveling back into the ureter and up to the kidney.)

The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms should the nurse monitor for? Select all that apply . 1. Anorexia 2. Dizziness 3. Weight loss 4. Moon face 5. Hypertension 6. Truncal obesity

4. Moon face 5. Hypertension 6. Truncal obesity A client with Cushing's syndrome may exhibit a number of different manifestations. These could include moon face, truncal obesity, and a buffalo hump fat pad. Other signs include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

A client with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis and a serum glucose level of 789 mg/dL (45 mmol/L). The health care provider (HCP) prescribes 10 units of regular insulin by intravenous (IV) bolus, followed by a continuous insulin infusion at a rate of 5 units/hr. The pharmacy sends 500 mL of normal saline solution containing 50 units of regular insulin. After administering the IV bolus of 10 units of regular insulin, the nurse sets the infusion pump flow rate of the normal saline solution containing 50 units of regular insulin to infuse at how many milliliters per hour to deliver 5 units/hr? Fill in the blank.

50 mL

The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? 1. A large skeletal frame 2. A diet low in vitamin D 3. Low thyroid hormone levels 4. A high dietary intake of calcium

A diet low in vitamin D Some of the risk factors related to osteoporosis in females are a small skeletal frame and elevated thyroid hormone. Low dietary intake of calcium and vitamin D also constitutes a risk factor for osteoporosis.

The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? 1. Advance the crutches along with both legs simultaneously. 2. Advance the crutches along with the right leg, and then advance the left leg. 3. Advance the crutches along with the left leg, and then advance the right leg. 4. Advance the left leg along with right crutch, and then the right leg and left crutch.

Advance the crutches along with the left leg, and then advance the right leg. A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a swing-through gait. Option 2 describes a three-point gait used for a right leg problem. Option 4 describes a two-point gait.

A 55-year-old male died in a motor vehicle accident. Autopsy revealed an enlarged liver caused by fatty infiltration, testicular atrophy, and mild jaundice secondary to cirrhosis. The most likely cause of his condition is:

Alcoholism Response Feedback: The most common cause of cirrhosis is alcoholism.

The nurse cares for a pregnant client who has a fetus diagnosed with anencephaly. After the primary healthcare provider discusses the prognosis with the parents, which action should the nurse take?

Allow the parents to grieve as the fetus will not survive

A 33-year-old female client is admitted to the hospital with a tentative diagnosis of Graves' disease. Which symptom related to the menstrual cycle would the client be most likely to report during the initial assessment? 1. Amenorrhea 2. Menorrhagia 3. Metrorrhagia 4. Dysmenorrhea

Amenorrhea Amenorrhea or a decreased menstrual flow occurs in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they are not typical manifestations of Graves' disease.

The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? 1. Allergic 2. Metabolic 3. Endocrine 4. Autoimmune

Autoimmune The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction.

A 24-year-old male who sustained a head injury and fractured femur develops a stress ulcer. A common clinical manifestation of this ulcer is:

Bleeding Response Feedback: The most common clinical manifestation is bleeding.

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? 1. Weight 2. Urine ketones 3. Blood pressure 4. Skin temperature

Blood pressure 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.

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? 1. Infertility 2. Gynecomastia 3. Sexual dysfunction 4. Body image changes

Body image changes Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia. Sexual dysfunction and infertility could occur if the entire thyroid is removed and the client is not placed on thyroid replacement medications.

The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which should the nurse assess to obtain the best information about the bone remodeling process? 1. Vitamin C 2. Vitamin A 3. Calcitonin 4. Thyroid hormone

Calcitonin Bone remodeling is the result of osteoblastic and osteoclastic activities, which are influenced by the degree of stress that is placed on the bone. The three substances that play an important role in this process are parathyroid hormone (which regulates calcium levels and bone resorption), vitamin D (which is active in bone formation and calcium resorption from bone), and calcitonin (which antagonizes parathyroid hormone and inhibits bone resorption). The other substances listed do not play a role in this process.

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1. Provide pin care. 2. Medicate the client. 3. Call the health care provider. 4. Remove 2 pounds (0.9 kg) of weight from the traction system.

Call the health care provider. Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so.

A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? 1. Remove the client's shoes. 2. Place the client in a semi Fowler's position. 3. Check the neurovascular status of the area distal to the extremity. 4. Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.

Check the neurovascular status of the area distal to the extremity. To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill. Tourniquets are not used to control hemorrhage in extremities because of the risk of tissue ischemia. Direct pressure is applied at the site and over the proximal artery nearest the fracture if bleeding occurs. Clients need to be kept in a supine position to help prevent hypotension and shock. Shoes are not removed because this action may cause increased trauma.

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to ensure that they are resting on a firm surface.

Check the weights to ensure that they are off of the floor. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights should not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? 1. Crutches and the affected leg down, followed by the unaffected leg 2. Crutches and the unaffected leg down, followed by the affected leg 3. Unaffected leg down first, followed by the crutches and the affected leg 4. Affected leg down first, followed by the crutches and the unaffected leg

Crutches and the affected leg down, followed by the unaffected leg When going down the stairs with crutches, the client should be instructed to move the crutches and the affected leg down and then to move the unaffected leg down. To go up the stairs, the client should first move up the unaffected leg and then move up the affected leg and crutches.

A nurse is caring for a client who had a thyroidectomy 1 day ago. Which client laboratory data should the nurse identify as a possible complication of thyroid surgery? 1. Increased serum sodium level 2. Increased serum glucose level 3. Decreased serum calcium level 4. Decreased serum albumin level

Decreased serum calcium level Hypocalcemia may occur if the parathyroid glands are removed or damaged or if their blood supply is impaired during thyroid surgery, resulting in decreased parathyroid hormone (PTH) levels and leading to decreased serum calcium levels. Serum sodium, albumin, and glucose levels are not affected by thyroid surgery.

The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? 1. Document the findings. 2. Notify the health care provider (HCP). 3. Remove 2 pounds (0.9 kg) of weight from the traction. 4. Lift the weights and place them on the bed so that the HCP can assess the client.

Document the findings. A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the HCP. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Thin, silky hair 3. Bulging eyeballs 4. Fine muscle tremors

Dry skin Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features; dry skin; and dry, coarse hair and eyebrows. The remaining options are noted in the client with hyperthyroidism.

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? 1. Fever and chills 2. Dyspnea and chest pain 3. External rotation of the right leg 4. Pallor, paresthesia, and pulselessness of the right lower leg

Dyspnea and chest pain The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment.

The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time? 1. Elevate the foot of the bed. 2. Position the residual limb flat on the bed. 3. Put the bed in a reverse Trendelenburg's position. 4. Keep the residual limb flat, with the client lying on his or her operative side.

Elevate the foot of the bed. Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the residual limb is placed flat on the bed to reduce hip contracture. Edema is also controlled by residual limb wrapping techniques.

The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? 1. Elevate the limb slightly. 2. Elevate the limb above heart level. 3. Keep the leg horizontal and cover the limb with bath blankets. 4. Place the leg in a slightly dependent position, and apply ice to the affected leg.

Elevate the limb slightly. Compartment syndrome is prevented by controlling edema. Elevation of the extremity may lower venous pressure and slow arterial perfusion; thus, the extremity should not be elevated above the heart. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to bivalve or split the cast in half if compartment syndrome is suspected. Covering the limb with bath blankets, and keeping the leg horizontal or in a dependent position would not be beneficial in controlling edema.

The most common disorder associated with upper GI bleeding is:

Esophageal varices (Response Feedback: Esophageal varices is the most common disorder associated with upper GI bleeding.)

Clinical manifestations of bile salt deficiencies are related to poor absorption of:

Fats and fat-soluble vitamins Response Feedback: Clinical manifestations of bile salt deficiency are related to poor intestinal absorption of fat and fat-soluble vitamins (A, D, E, K).

The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? 1. Fractures 2. Weight loss 3. Hypocalcemia 4. Muscle atrophy

Fractures Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility. The woman is most likely to suffer fractures as a result of this disorder. The remaining options are not directly related to this disorder.

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture

Impaired tissue perfusion Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? 1. Lack of control 2. Lack of physical mobility 3. Inability to entertain self 4. Inability to maintain health

Inability to entertain self A manifestation of the inability to entertain self is expression of boredom by the client. The question does not identify difficulties with coordination, range of motion, or muscle strength, which would indicate lack of physical mobility. The question also does not relate to client feelings of inability to take responsibility for meeting basic health practices (inability to maintain health) or to lack of control.

The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? 1. Increased use of glucose 2. Overproduction of insulin 3. Increased production of glucose 4. Increased osmotic movement of water

Increased production of glucose Hyperglycemia results from decreased use and increased production of glucose. Increased use of glucose and overproduction of insulin would most likely cause hypoglycemia. Option 4 is incorrect.

A client's serum blood glucose level is 389 mg/dL (22.2 mmol/L). The nurse would expect to note which as an additional finding when assessing this client? 1. Unsteady gait 2. Slurred speech 3. Increased thirst 4. Cold, clammy skin

Increased thirst A clinical manifestation of hyperglycemia is increased thirst secondary to dehydration and frequent urination. Unsteady gait; slurred speech; and cold, clammy skin would most likely be noted in hypoglycemia.

A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? 1. Give pin care once a shift. 2. Inspect the skin on the right leg. 3. Massage the skin of the right leg with lotion. 4. Release the weights on the right leg for daily range-of-motion exercises.

Inspect the skin on the right leg. Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. There are no pins to care for with skin traction. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the health care provider.

A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? 1. It induces muscle relaxation. 2. It prevents abscess formation. 3. It reduces the likelihood of strain as a complication. 4. It promotes reabsorption of blood from the injured tissue.

It promotes reabsorption of blood from the injured tissue. The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to reduce abscess formation or prevent muscle strain.

A 50-year-old male is experiencing reflux of chyme from the stomach. He is diagnosed with gastroesophageal reflux. This condition is caused by:

Loss of muscle tone at the lower esophageal sphincter (Response Feedback: Gastroesophageal reflux is due to loss of muscle tone at the lower esophageal sphincter.)

Which term should the nurse use to describe disorders of lipid metabolism?

Lysosomal storage diseases

Which pediatric brain tumors are found in the infratentorial region of the brain? Select all that apply.

Medulloblastomas, Brainstem gliomas, Cerebellar astrocytomas

Complications obstruction in the lower bowel include

Metabolic acidosis Tachycardia Hypovolemia Peritonitis With obstruction lower in the intestine, metabolic acidosis is more likely to occur because bicarbonate from pancreatic secretions and bile cannot be reabsorbed. Hypokalemia can be extreme. Continued intestinal secretion and decreased absorption lead to decreased blood volume and elevates hematocrit, decreases central venous pressure, and causes tachycardia. Severe dehydration leads to hypovolemic shock. Bacteria also proliferate and may cross the mucosal barrier and cause peritonitis or sepsis.

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? 1. Dry sterile dressings 2. Hydrocolloid dressings 3. Moist sterile saline dressings 4. One-half strength povidone-iodine dressings

Moist sterile saline dressings The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Because this is an open wound, dry dressings should not be used. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine should not be required. Also, this agent is irritating to tissues.

During physical examination of a client, which finding is characteristic of hypothyroidism? 1. Periorbital edema 2. Flushed, warm skin 3. Hyperactive bowel sounds 4. Heart rate of 120 beats/min

Periorbital edema Because cellular edema occurs in hypothyroidism, the client's appearance is changed. Nonpitting edema occurs, especially around the eyes and in the feet and hands. Knowing this should direct you to option 1. Flushed, warm skin; hyperactive bowel sounds; and tachycardia (heart rate >100 beats/min) are clinical manifestations of hyperthyroidism, which occurs as a result of excess thyroid hormone secretion, resulting in a hypermetabolic state.

The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? 1. Massage the skin at the rim of the cast. 2. Petal the cast edges with adhesive tape. 3. Use a rough file to smooth the cast edges. 4. Apply lotion to the skin at the rim of the cast.

Petal the cast edges with adhesive tape. The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging the skin and applying lotion will not alleviate irritation. Using a rough file could cause increased irritation.

A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder? 1. Polyuria 2. Diarrhea 3. Polyphagia 4. Weight gain

Polyuria Hypercalcemia classically occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis, making polyuria the correct option. The other manifestations listed are not associated with this disorder.

The nurse is caring for a client admitted to the hospital with uncontrolled type 1 diabetes mellitus. In the event that diabetic ketoacidosis (DKA) does occur, the nurse anticipates that which medication would most likely be prescribed? 1. Glucagon 2. Glyburide 3. Regular insulin 4. Neutral protamine Hagedorn (NPH) insulin

Regular insulin Giving regular insulin by the intravenous route is the treatment of choice for DKA. A short-acting insulin is the only insulin that can be given intravenously because it can be titrated to the client's blood glucose levels. Glucagon is used to treat hypoglycemia because it increases blood glucose levels, and glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus; both agents are inappropriate. NPH insulin is an intermediate-acting insulin and therefore is not appropriate for treatment of DKA.

What is a clinical manifestation of a right-sided cerebellar astrocytoma in a child?

Right head tilt: A right sided cerebellar astrocytoma will cause right-sided symptoms. Cerebellar astrocytomas are located on the surface of the right or left cerebellar hemisphere and cause unilateral symptoms (occurring on the same side as the tumor), such as head tilt, limb ataxia, and nystagmus.

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? 1. Telling the client that the saw makes a frightening noise 2. Reassuring the client that no one has had an arm lacerated yet 3. Stating that the hot cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works

Showing the client the cast cutter and explaining how it works Individuals may be fearful of having a cast removed because of misconceptions about the cast-cutting blade. The nurse should show the cast cutter to the client before it is used and explain that he or she may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. The remaining options will increase the client's fear about the procedure.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

Signs of skin breakdown Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

A child diagnosed with cerebral palsy has increased muscle tone, prolonged primitive reflexes, scoliosis, and contractures. Which form of cerebral palsy does this child have?

Spastic

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? 1. Tuberculin test 2. Tetanus vaccine 3. Chest radiograph 4. Physical examination

Tetanus vaccine With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.

The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

b. Corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, higher motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? 1. The client's mobility status 2. The renal and endocrine systems 3. The cardiovascular and renal systems 4. The neurological and respiratory systems

The neurological and respiratory systems The early signs of the complication of fat embolism include changes in the client's mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client's mobility status is unrelated to the signs of fat embolism.

The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? 1. Signs of infection are absent. 2. The muscles are beginning to relax. 3. Abscess formation has not occurred. 4. There is reabsorption of blood noted at the injured site.

There is reabsorption of blood noted at the injured site. The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to prevent infection or abscess formation.

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? 1. Bradycardia 2. Flaccid paralysis 3. Tingling around the mouth 4. Absence of Chvostek's sign

Tingling around the mouth After thyroidectomy the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and in the fingertips, muscle twitching or spasms, palpitations or arrhythmias, and Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of Chvostek's sign are not signs of hypocalcemia.

A nurse is caring for a client after a thyroidectomy. Which specific emergency equipment should the nurse have available as it relates to this procedure? 1. Defibrillator 2. Tracheostomy tray 3. Dextrose 50% in water 4. Normal saline for intravenous bolus

Tracheostomy tray After thyroidectomy, airway obstruction, although not common, can occur. This is considered an emergency situation. If this develops, emergency management needs to occur and oxygen, suction equipment, and a tracheostomy tray should be immediately available at the bedside. The other supplies are not necessary specifically for thyroidectomy.

During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Change in scrotal color. b. Decrease in the size of the penis. c. Enlargement of the testes and scrotum. d. Increase in the number of rugae over the scrotal sac.

b. Decrease in the size of the penis. When assessing the genitals of an older man, the nurse may notice thinner, graying pubic hair and a decrease in the size of the penis. The size of the testes may be decreased, they may feel less firm, and the scrotal sac is pendulous with less rugae. No change in scrotal color is observed.

The term rugae refers to: a. a corpus spongiosum cone of erectile tissue. b. folds of thin skin of the scrotal wall. c. a muscle that controls the size of the scrotum. d. an acute inflammation of the testes.

b. folds of thin skin of the scrotal wall. The scrotum wall consists of thin skin lying in folds, or rugae, and the underlying cremaster muscle. The penis is composed of three cylindrical columns of erectile tissue: two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. The cremaster muscle controls the size of the scrotum. Orchitis is an acute inflammation of the testes.

Adnexa is (are): a. an absence of menstruation. b. uterine accessory organs. c. a membranous fold of tissue partly closing the vaginal orifice. d. painful intercourse.

b. uterine accessory organs. The adnexa of uterus (or uterine appendages) refers to the structures most closely related structurally and functionally to the uterus; these structures include the ovaries, fallopian tubes, and ligaments. Amenorrhea is the absence of menstruation. The hymen is a thin, circular or crescent-shaped fold that may cover part of the vaginal orifice or may be absent completely. Dyspareunia is the term to describe painful intercourse.

A patient has had three pregnancies and two live births. The nurse would record this information as grav _____, para _____, AB _____. a. 2; 2; 1 b. 3; 2; 0 c. 3; 2; 1 d. 3; 3; 1

c. 3; 2; 1

A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. The nurse should: a. Tell him not to worry and that most men his age develop hernias. b. Explain that a hernia is often the result of prenatal growth abnormalities. c. Refer him to his physician for additional consultation because the physician made the initial diagnosis. d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles. A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options are not correct responses to the patients question.

A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask: a. Do you have a history of heart murmurs? b. Will you be in a monogamous relationship? c. Have you carefully thought this choice through? d. If you smoke, how many cigarettes do you smoke per day?

d. If you smoke, how many cigarettes do you smoke per day? Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects.

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1. "I need to eat foods high in potassium." 2. "I need to drink at least 2 to 3 L of fluid daily." 3. "I need to eat small, frequent meals and snacks if nauseated." 4. "I need to increase my intake of dietary items that are high in calcium."

"I need to increase my intake of dietary items that are high in calcium." The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption of calcium. Dietary restriction of calcium may be used as a component of therapy. The client should eat foods high in potassium, especially if the client is taking furosemide. Drinking 2 to 3 L of fluid daily and eating small, frequent meals and snacks if nauseated are appropriate instructions for the client.

A hospitalized client is experiencing an episode of hypoglycemia. The client is lethargic and has no available intravenous (IV) access. Which medication should the nurse anticipate administering? 1. Insulin 2. Cortisone 3. Glucagon 4. Epinephrine

Glucagon Glucagon, a natural hormone secreted by the pancreas, is available as a subcutaneous injection to be given when a quick response to severe hypoglycemia is needed. Glucagon is useful in the unconscious hypoglycemic client without established IV access. The remaining options are incorrect treatments.

The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse should tell the client that which would be noted in a hypoglycemic reaction? 1. Thirst 2. Hunger 3. Polydipsia 4. Increased urine output

Hunger Signs and symptoms of hypoglycemia include hunger, nervousness, anxiety, dizziness, blurred vision, sweaty palms, confusion, and tingling and numbness around the mouth. Polydipsia (thirst) and increased urine output are noted in the client with hyperglycemia.

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? 1. Glycosuria 2. Diaphoresis 3. Weight loss 4. Hypertension

Hypertension 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.

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension

Hypotension Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. The remaining options do not occur with this disease.

Which of the following conditions is thought to contribute to the development of obesity?

Leptin resistance Response Feedback: Leptin resistance disrupts hypothalamic satiety signaling and promotes overeating and excessive weight gain and is a factor in the development of obesity.

A 4-year old child has a white pupillary reflex. Which medical term should the nurse use to describe this finding?

Leukocoria: The primary sign of retinoblastoma is leukocoria, a white pupillary reflex also called cat's eye reflex which is caused by the mass behind the lens.

Chronic gastritis is classified according to the:

Location of lesions Response Feedback: Chronic gastritis is classified as type A (fundal) or type B (antral), depending on the pathogenesis and location of the lesions.

A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse should take which immediate action? 1. Test the client's stool for guaiac. 2. Notify the health care provider. 3. Administer the prescribed as-needed antacid. 4. Administer the prescribed as-needed antiemetic.

Notify the health care provider. The client who has been placed in a body cast is at risk for the development of cast syndrome. This results from pressure on the mesenteric artery and can lead to intestinal obstruction. The immediate action is to report the client's complaints to the health care provider (HCP). Cast syndrome usually is treated with nasogastric decompression, intravenous therapy for hydration, and possibly application of a new cast. Testing the stool and administering an antacid or antiemetic delay necessary interventions.

A 52-year-old female presents with continuous abdominal pain that intensifies after eating. She is diagnosed with chronic pancreatitis. Contributing factors include: (Select all that apply.)

Peptic ulcer disease Trauma Smoking Pancreatitis can be acute or chronic, and risk factors include alcoholism, obstructive biliary tract disease (particularly cholelithiasis), peptic ulcers, trauma, hyperlipidemia, and smoking, as well as certain drugs.

A 42-year-old female presents with abdominal discomfort, epigastric tenderness, and bleeding. Gastroscopy reveals degeneration of the gastric mucosa in the body and fundus of the stomach. Which of the following would most likely follow?

Pernicious anemia Response Feedback: Pernicious anemia can develop because the damage to the mucosa makes the intrinsic factor less available to facilitate

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? 1. Unresponsive pupils 2. Positive Trousseau's sign 3. Negative Chvostek's sign 4. Hyperactive bowel sounds

Positive Trousseau's sign Hypoparathyroidism is related to a lack of parathyroid hormone secretion or a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit Chvostek's and Trousseau's signs, which indicate potential tetany. The remaining options are not related to the presence of hypocalcemia.

Which assessment finding would alert the nursery nurse that there is a separation of the cranial sutures in a newborn?

Presence of the Macewen sign

A child is diagnosed with Tay-Sachs disease. Which clinical manifestations should the nurse find upon assessment?

Seizures, dementia, and blindness

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

Separation of the wound edges Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact.

During routine nursing assessment after hypophysectomy, a client complains of thirst and frequent urination. Knowing the expected complications of this surgery, what should the nurse assess next? 1. Serum glucose 2. Blood pressure 3. Respiratory rate 4. Urine specific gravity

Urine specific gravity After hypophysectomy, temporary diabetes insipidus can result from antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should assess urine specific gravity and notify the health care provider if the result is less than 1.005. Although the remaining options may be components of the assessment, the nurse would next assess urine specific gravity.

During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal? a. Cervix b. Uterus c. Ovaries d. Fallopian tubes

a. Cervix

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

a. Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).

During an examination, the nurse observes a female patients vestibule and expects to see the: a. Urethral meatus and vaginal orifice. b. Vaginal orifice and vestibular (Bartholin) glands. c. Urethral meatus and paraurethral (Skene) glands. d. Paraurethral (Skene) and vestibular (Bartholin) glands.

a. Urethral meatus and vaginal orifice.

The nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause? a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy

a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium

The presence of primitive reflexes in a newborn infant is indicative of: a. immaturity of the nervous system. b. prematurity of the infant. c. mental retardation. d. spinal cord alterations.

a. immaturity of the nervous system. The nervous system is not completely developed at birth, and motor activity in the newborn is under the control of the spinal cord and medulla. The neurons are not yet myelinated. Movements are directed primarily by primitive reflexes. As the cerebral cortex develops during the first year, it inhibits these reflexes, and they disappear at predictable times. Persistence of the primitive reflexes is an indication of central nervous system dysfunction.

The penis: a. is composed of two corpora cavernosa and one corpus spongiosum. b. is a loose protective sac that is a continuation of the abdominal wall. c. and scrotum are the internal structures of the male genitals. d. size is controlled by the cremaster muscle.

a. is composed of two corpora cavernosa and one corpus spongiosum. The penis is composed of three cylindrical columns of erectile tissue: two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. The scrotum is a loose protective sac that is a continuation of the abdominal wall. The penis and scrotum are the external structures of the male genitals; the internal structures are the testis, epididymis, and vas deferens. The cremaster muscle controls the size of the scrotum.

A nurse is assessing a patients risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: a. You know that its important to use condoms for protection, right? b. Do you use a condom with each episode of sexual intercourse? c. Do you have a sexually transmitted infection? d. You are aware of the dangers of unprotected sex, arent you?

b. Do you use a condom with each episode of sexual intercourse? In reviewing a patients risk for STIs, the nurse should ask in a nonconfrontational manner whether condoms are being used during each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.

The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation? a. In the parents lap b. In a frog-leg position on the examining table c. In the lithotomy position with the feet in stirrups d. Lying flat on the examining table with legs extended

b. In a frog-leg position on the examining table For school-age children, placing them on the examining table in a frog-leg position is best. With toddlers and preschoolers, having the child on the parents lap in a frog-leg position is best.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

b. May indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n): a. additional contraction of the muscle that is of greater intensity than the first contraction. b. set of rapid, rhythmic contractions of the same muscle. c. parallel response in the opposite extremity. d. contraction of the muscle that appears after the tendon is hit the second time.

b. set of rapid, rhythmic contractions of the same muscle. Clonus is a set of rapid, rhythmic contractions of the same muscle.

Generally, the changes normally associated with menopause occur because the cells in the reproductive tract are: a. Aging. b. Becoming fibrous. c. Estrogen dependent. d. Able to respond to estrogen.

c. Estrogen dependent.

_____________ is acute inflammation of the testes. a. Genital herpes b. Priapism c. Orchitis d. Paraphimosis

c. Orchitis Orchitis is an acute inflammation of the testes. Genital herpes is a sexually transmitted infection caused by the herpes simplex virus; the vesicles erupt on the glans or foreskin. Priapism is a prolonged painful erection of the penis. Paraphimosis occurs when the foreskin is retracted and fixed.

The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

c. Spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurses interpretation of these results should be which of these? a. These findings are all within normal limits. b. Cervical consistency should be soft and velvety not firm. c. The cervix should move when palpated; an immobile cervix may indicate malignancy. d. Pain may occur during palpation of the cervix.

c. The cervix should move when palpated; an immobile cervix may indicate malignancy. Normally, the cervix feels smooth and firm, similar to the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy.

The extrapyramidal system is located in the: a. hypothalamus. b. cerebellum. c. basal ganglia. d. medulla.

c. basal ganglia. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system).

Decreased estrogen levels during menopause cause: a. an enlargement of the uterus. b. pelvic muscles and ligaments to tighten. c. the ovaries to atrophy. d. the cervix to enlarge and turn blue.

c. the ovaries to atrophy. Decreased estrogen levels during menopause cause atrophy of the ovaries. Decreased estrogen levels during menopause cause the uterus to shrink related to a decrease in the myometrium. Decreased estrogen levels during menopause cause the sacral ligaments to relax and the pelvic musculature to weaken, which causes the uterus to drop. Decreased estrogen levels during menopause cause the cervix to shrink and look pale with a thick, glistening epithelium.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

d. Decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

d. Hyperactive reflexes Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

Which of these statements is true regarding the penis? a. The urethral meatus is located on the ventral side of the penis. b. The prepuce is the fold of foreskin covering the shaft of the penis. c. The penis is made up of two cylindrical columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.

d. The corpus spongiosum expands into a cone of erectile tissue called the glans. At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The penis is made up of three cylindrical columns of erectile tissue. The skin that covers the glans of the penis is the prepuce. The urethral meatus forms at the tip of the glans.

Dysmenorrhea is: a. painful intercourse. b. pain with defecation. c. pain with urination. d. pain associated with menstruation.

d. pain associated with menstruation. Dysmenorrhea is the abdominal cramping and pain associated with menstruation. Dyspareunia is the term to describe painful intercourse. Dyschezia is pain with bowel movements. Dysuria describes pain or burning with urination.

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet." 2. "I should eat foods that have a lot of potassium in them." 3. "I am fortunate that I can eat all of the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

"I should eat foods that have a lot of potassium in them." A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands instructions? 1. "I will decrease my carbohydrate intake." 2. "High fat intake is essential with this disease." 3. "I will maintain a normal sodium intake in my diet." 4. "I will need to restrict the amount of protein in my diet.

"I will maintain a normal sodium intake in my diet." A high-complex carbohydrate, high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high-fat diet is not prescribed.

A parent asks the nurse what the term craniosynostosis means. Which response by the nurse is best?

"It is a birth defect in which a joint between the bones of a baby's skull closes too early."

The nurse is interviewing a client with type 2 diabetes mellitus who is taking a sulfonylurea. Which statement by the client indicates an understanding of this treatment for this disorder? 1. "I take oral insulin instead of shots." 2. "By taking this medication, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." 4. "The medications I'm taking help release the insulin I already make."

"The medications I'm taking help release the insulin I already make." Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Therefore, the remaining options are incorrect.

The home care nurse is visiting a client newly diagnosed with diabetes mellitus. The client tells the nurse that he is planning to eat dinner at a local restaurant this week. The client asks the nurse if eating at a restaurant will affect diabetic control and if this is allowed. Which nursing response is most appropriate? 1. "You are not allowed to eat in restaurants." 2. "You should order a half-portion meal and have fresh fruit for dessert." 3. "If you plan to eat in a restaurant, you need to skip the lunchtime meal." 4. "You should increase your daily dose of insulin by half on the day that you plan to eat in the restaurant."

"You should order a half-portion meal and have fresh fruit for dessert." Clients with diabetes mellitus are instructed to make adjustments in their total daily intake to plan for meals at restaurants or parties. Some useful strategies include ordering a half-portion, salads with dressing on the side, fresh fruit for dessert, and baked or steamed entrees. Clients are not instructed to skip meals or increase their prescribed insulin dosage.

The nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply. 1. Proteinuria 2. Hematuria 3. Positive ketones 4. A low specific gravity 5. A dark and smoky appearance of the urine

1, 2, 5 (► In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. ► The specific gravity is elevated, and the urine may appear dark and smoky. ► Positive ketones are not associated with this condition but may indicate a secondary problem.)

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3 (► Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. ► Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. ► Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.)

The nurse has administered a dose of meperidine hydrochloride to a client with renal colic as treatment for pain. The nurse carefully monitors this client for which side and adverse effect of this medication? 1. Bradycardia 2. Hypertension 3. Urinary retention 4. Increased respirations

3 (► Meperidine hydrochloride is an opioid analgesic. ► Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention.)

The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement made by the new nursing graduate indicates an understanding of the procedure for hemodialysis? Select all that apply. 1. "Sterile dialysate must be used." 2. "Dialysate contains metabolic waste products." 3. "Heparin sodium is administered during dialysis." 4. "Dialysis cleanses the blood of accumulated waste products." 5. "Warming the dialysate increases the efficiency of diffusion."

3, 4, 5 (► Heparin sodium is used during dialysis, and it inhibits the tendency of blood to clot when it comes in contact with foreign substances. ► Option 4 is the purpose of dialysis. ► The dialysate is warmed to approximately 100°F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. ► Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. ► Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile.)

A client with chronic kidney disease (CKD) is prescribed aluminum hydroxide. Which information should the nurse include while instructing the client regarding the action of this medication? 1. It prevents ulcers. 2. It prevents constipation. 3. It promotes the elimination of potassium from the body. 4. It combines with phosphorus and helps eliminate phosphates from the body.

4 (► Aluminum hydroxide may be prescribed for a client with CKD. It binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. ► It can cause constipation, and it does not promote the elimination of potassium. ► It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure.)

The nurse is preparing to care for a client after a renal scan. Which intervention should the nurse include in the postprocedure plan of care? 1. Limit contact with the client to 20 minutes per hour. 2. Place the client on radiation precautions for 18 hours. 3. Save all urine in a radiation-safe container for 18 hours. 4. Wear gloves if contact with the client's urine will occur.

4 (► No specific precautions are necessary after a renal scan. ► Urination into a commode is acceptable without risk from the small amount of radioactive material to be excreted. ► The nurse wears gloves to maintain body secretion precautions. ► Options 1, 2, and 3 are unnecessary.

The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? 1. 3 inches (8 cm) to the front and side of the toes 2. 6 inches (15 cm) to the front and side of the toes 3. 15 inches (38 cm) to the front and side of the toes 4. 20 inches (51 cm) to the front and side of the toes

6 inches (15 cm) to the front and side of the toes The classic tripod position is taught to the client before instructions on gait are given. The crutches are placed 6 inches (15 cm) in front and to the side of the client. This placement provides an adequate base of support to the client and improves balance.

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for a diagnostic test 4. A client with diabetes mellitus scheduled for debridement of a foot ulcer

A client with Graves' disease who is having surgery Thyrotoxicosis usually is seen in clients with Graves' disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy. The client conditions in the remaining options are not associated with thyrotoxicosis.

Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? 1. Platelet count 2. Alkaline phosphatase 3. White blood cell count 4. Complete blood cell count

Alkaline phosphatase Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline phosphatase level and elevated urinary hydroxyproline excretion. The remaining options are unrelated to diagnostic evaluation of this disease.

A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance? 1. Melatonin excess or deficit 2. Glucocorticoid excess or deficit 3. Mineralocorticoid excess or deficit 4. Antidiuretic hormone (ADH) excess or deficit

Antidiuretic hormone (ADH) excess or deficit The hypothalamus exerts an influence on both the anterior and the posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The pineal gland is responsible for melatonin production. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids

A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? 1. Carrots 2. Tapioca 3. Chocolate 4. Chicken liver

Chicken liver Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

Which pediatric client is most likely to be diagnosed with an inherited form of retinoblastoma?

A 6-month-old infant who has strabismus

A 60-year-old female with a history of alcoholism complains of recent weight gain and right flank pain. Physical examination reveals severe ascites. This condition is caused by decreased:

Albumin and lack of cellular integrity Response Feedback: Ascites is due to decreased albumin and lack of cellular integrity.

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Bulging eyeballs 3. Periorbital edema 4. Coarse facial features

Bulging eyeballs Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.

Pancreatic insufficiency is manifested by deficient production of:

Lipase Response Feedback: Pancreatic insufficiency is the deficient production of lipase by the pancreas.

The nurse monitoring a client receiving *peritoneal dialysis* notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1, 2, 4, 5 (► If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. ► Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. ► The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. ► The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. ► There is no reason to contact the HCP. ► Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.)

The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions should be included on the list? Select all that apply. 1. The signs and symptoms of hypoadrenalism 2. The signs and symptoms of hyperadrenalism 3. Instructions to take the medications exactly as prescribed 4. The importance of maintaining regular outpatient follow-up care 5. A reminder to read the labels on over-the-counter medications before purchase

1. The signs and symptoms of hypoadrenalism 2. The signs and symptoms of hyperadrenalism 3. Instructions to take the medications exactly as prescribed 4. The importance of maintaining regular outpatient follow-up care The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the health care provider (HCP) before purchasing any over-the-counter medications, and maintaining regular outpatient follow-up care. The nurse also should instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.

A hospitalized client is diagnosed with type 1 diabetes mellitus. The nurse plans care for the client, understanding that which factors are likely causes of the beta cell destruction that accompanies this disorder? Select all that apply. 1. Viruses 2. Genetic factors 3. Autoimmune factors 4. Human leukocyte antigen (HLA) 5. Primary failure of glucagon secretion

1. Viruses 2. Genetic factors 3. Autoimmune factors 4. Human leukocyte antigen (HLA) Viruses and autoimmune factors are thought to play a role in the development of type 1 diabetes mellitus. Other causes of type 1 diabetes mellitus include genetic factors, specifically the presence of HLA. This factor is found in many clients with type 1 diabetes mellitus. The problem with type 1 diabetes mellitus is destruction of the beta cells. It is not caused by a primary failure of glucagon secretion.

The nurse has provided instructions to a client with a urinary tract infection (UTI) regarding foods and fluids to consume that will acidify the urine. Which fluids should the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply. 1. Milk 2. Prune juice 3. Apricot juice 4. Cranberry juice 5. Carbonated drinks

2, 3, 4 (► Acidification of the urine inhibits multiplication of bacteria. ► Fluids that acidify the urine include prune, apricot, cranberry, and plum juice. ► Carbonated drinks should be avoided because they increase urine alkalinity. ► Two glasses of milk a day can make the urine more alkaline, which could aid in the development of kidney stones.)

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply 1. Irritability 2. Periorbital edema 3. Coarse, brittle hair 4. Slow or slurred speech 5. Abdominal distention 6. Soft, silky, thinning hair

2. Periorbital edema 3. Coarse, brittle hair 4. Slow or slurred speech 5. Abdominal distention The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. The client may exhibit skin manifestations, such as coarse, brittle hair; thick, brittle nails; coarse, scaly skin; delayed wound healing; periorbital edema; and face puffiness. Neuromuscular manifestations include lethargy, slow or slurred speech, and impaired memory. Gastrointestinal manifestations include complaints of constipation, weight gain, and abdominal distention. Irritability and soft, silky, thinning hair on the scalp are manifestations of hyperthyroidism.

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? 1. During dialysis 2. Just before dialysis 3. The day after dialysis 4. On return from dialysis

4 (► Antihypertensive medications such as enalapril are given to the client following hemodialysis. ► This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. ► No rationale exists for waiting an entire day to resume the medication. ► This would lead to ineffective control of the blood pressure.

A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? 1. A 2. D 3. E 4. K

D Osteomalacia technically refers to bone softening that results from demineralization of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of the vitamins noted in the remaining options are not associated with osteomalacia.

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24 to 48 hours

Elevated on pillows continuously for 24 to 48 hours A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.

A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit a sign of thyroid storm. Which is an early indicator of this complication? 1. Bradycardia 2. Constipation 3. Hyperreflexia 4. Low-grade temperature

Hyperreflexia Clinical manifestations of thyroid storm include a fever as high as 106°F, hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severe tachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascular collapse.

The icteric phase of hepatitis is characterized by which of the following clinical manifestations?

Jaundice, dark urine, enlarged liver Response Feedback: The icteric phase is manifested by jaundice, dark urine, and clay-colored stools. The liver is enlarged, smooth, and tender, and percussion causes pain; this is the actual phase of illness.

The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? 1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials

Overhead trapeze The use of an overhead trapeze is extremely helpful for a client to move about in bed and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. Television and reading materials, although helpful in reducing boredom and providing distraction, do not increase bed mobility. A fracture bedpan is useful in reducing discomfort with elimination.

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

a. Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a persons ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

A woman has just been diagnosed with HPV or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _______ cancer. a. Uterine b. Cervical c. Ovarian d. Endometrial

b. Cervical HPV is the virus responsible for most cases of cervical cancer, not the other options.

During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: a. Stellate. b. Small and round. c. As a horizontal irregular slit. d. Everted.

b. Small and round. The cervical os in a nulliparous woman is small and round. In the parous woman, it is a horizontal, irregular slit that also may show healed lacerations on the sides (see Figure 26-13).

A client's serum blood glucose level is 48 mg/dL (2.74 mmol/L). The nurse would expect to note which as an additional finding when assessing this client? 1. Slurred speech 2. Increased thirst 3. Increased appetite 4. Increased urination

Slurred speech A client who has a blood glucose level of less than 70 mg/dL (4 mmol/L) is considered to be hypoglycemic. A clinical manifestation of hypoglycemia is slurred speech.

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which concept? 1. Always keep insulin vials refrigerated. 2. Ketones in the urine signify a need for less insulin. 3. Increase the amount of insulin before excessive exercise. 4. Systematically rotate insulin injections within 1 anatomical site.

Systematically rotate insulin injections within 1 anatomical site. Injection sites should be rotated systematically within 1 anatomical site. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. If ketones are found in the urine, it may indicate the need for additional insulin. Insulin doses should not be adjusted or increased before excessive exercise.

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? 1. Obtaining the client's weight 2. Taking the client's blood pressure 3. Testing the client's urine for glucose 4. Palpating the skin for its temperature

Taking the client's blood pressure 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.

The nurse is caring for a client diagnosed with the rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected? 1. Nerve 2. Tendon 3. Ligament 4. Synovial fluid

Tendon Lesions of the rotator cuff often involve the supraspinatus tendon of the shoulder. Although the entire joint is painful, the etiology does not involve nerves, ligaments, or synovial fluid. Usually the problem involves one or more of the tendons and muscles in the musculotendinous cuff. It most often is the result of minor repeated traumas or degenerative changes in the older client or the result of severe trauma in the younger client.

When teaching the parents of a newborn diagnosed with phenylketonuria (PKU), which information should the nurse include?

Treatment includes dietary protein restrictions.

A 50-year-old male complains of frequently recurring abdominal pain, diarrhea, and bloody stools. A possible diagnosis would be:

Ulcerative colitis Response Feedback: Ulcerative colitis is manifested by fever, elevated pulse rate, frequent diarrhea (10 to 20 stools/day), urgency, obviously bloody stools, and continuous lesions present in the colon.

The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? 1. In 48 hours 2. In 24 hours 3. In approximately 8 hours 4. Within 20 to 30 minutes of application

Within 20 to 30 minutes of application A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. The remaining options are incorrect.

During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

a. Vertigo. True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

b. Central and peripheral. The nervous system can be divided into two partscentral and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

A married couple has come to the clinic seeking advice on pregnancy. They have been trying to conceive for 4 months and have not been successful. What should the nurse do first? a. Ascertain whether either of them has been using broad-spectrum antibiotics. b. Explain that couples are considered infertile after 1 year of unprotected intercourse. c. Immediately refer the woman to an expert in pelvic inflammatory diseasethe most common cause of infertility. d. Explain that couples are considered infertile after 3 months of engaging in unprotected intercourse and that they will need a referral to a fertility expert.

b. Explain that couples are considered infertile after 1 year of unprotected intercourse.

When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

c. Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

An accessory glandular structure for the male genital organs is the: a. Testis. b. Scrotum. c. Prostate. d. Vas deferens.

c. Prostate. Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands.

When the nurse is interviewing a preadolescent girl, which opening question would be least threatening? a. Do you have any questions about growing up? b. What has your mother told you about growing up? c. When did you notice that your body was changing? d. I remember being very scared when I got my period. How do you think youll feel?

c. When did you notice that your body was changing? Open-ended questions such as, When did you ? rather than Do you ? should be asked. Open-ended questions are less threatening because they imply that the topic is normal and unexceptional.

The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates an accurate understanding of CAPD? 1. "No machinery is involved, and I can pursue my usual activities." 2. "A cycling machine is used, so the risk for infection is minimized." 3. "The drainage system can be used once during the day and a cycling machine for 3 cycles at night." 4. "A portable hemodialysis machine is used so that I will be able to ambulate during the treatment."

1 (► CAPD closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. ► No machinery is used, and CAPD is a manual procedure.)

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1. "Changes in the shape of the knee are expected." 2. "Fever, redness, and increased pain are expected." 3. "All caregivers should be told about the metal implant." 4. "Bleeding gums or black stools may occur, but this is normal."

"All caregivers should be told about the metal implant. A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures.

The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? 1. "Do you have tremors in your hands?" 2. "Are you experiencing pain in your joints?" 3. "Do you notice swelling in your legs at night?" 4. "Have you had problems with diarrhea lately?"

"Are you experiencing pain in your joints?" Hyperparathyroidism is associated with oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and, sometimes, pathological fractures. Tremors and diarrhea relate to assessment findings of hypoparathyroidism. Swelling in the legs at night is unrelated to hyperparathyroidism.

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question? 1. "Are you rotating the injection site?" 2. "Are you aspirating before you inject the insulin?" 3. "Are you using a 1-inch needle to give the injection?" 4. "Are you placing an air bubble in the syringe before injection?"

"Are you rotating the injection site?" The client should be instructed that insulin injection sites should be rotated within 1 anatomical area before moving on to another area. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. The remaining options are not associated with the condition (skin leakage of insulin) presented in the question.

The nurse is preparing instructions for a client who is diagnosed with osteomalacia. Which information should the nurse include in the teaching? 1. "Avoid exposure to sunlight." 2. "Avoid weight-bearing exercise." 3. "Ensure adequate intake of vitamin D fortified foods." 4. "Osteomalacia and osteoporosis are interchangeable terms."

"Ensure adequate intake of vitamin D fortified foods." A common cause of osteomalacia is vitamin D deficiency, so the client should include adequate dietary intake of vitamin D-fortified foods. Other causes include inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with the absorption and metabolism of vitamin D. Osteomalacia technically refers to bone softening, which results from demineralization of bone matrix and its failure to calcify. This is different from osteoporosis, which is a metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility and pathologic fractures. Weight-bearing exercises are appropriate.

The nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instruction? 1. "I should avoid bed rest." 2. "I need to avoid doing any exercise at all." 3. "I need to space activity throughout the day." 4. "I should gauge my activity level by my energy level.

"I need to avoid doing any exercise at all." The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to avoid bed rest and use energy levels as a guide to activity. The client also should be instructed to avoid high-impact activity or contact sports.

A client with suspected Cushing's syndrome is scheduled for adrenal venography. A nurse has provided instructions to the client regarding the test. Which statement by the client indicates a need for further instruction? 1. "I need to sign an informed consent." 2. "The insertion site will be locally anesthetized." 3. "I will be placed in a high-sitting position for the test." 4. "I may feel a burning sensation after the dye is injected."

"I will be placed in a high-sitting position for the test." The test aids in determining whether signs and symptoms are caused by abnormalities in the adrenal gland. The nurse assesses the client for allergies to iodine before the test. The client is informed that the supine position is necessary to access the femoral vein. An informed consent form is required, the insertion site will be locally anesthetized, and the client will experience a transient burning sensation after the dye is injected

A client has been experiencing muscle weakness over a period of several months. The health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? 1. "If I have polymyositis, there will be a decrease in elastic tissue." 2. "I will know I have polymyositis if the muscle fibers are inflamed." 3. "The health care provider said there would be more fibers and tissue with polymyositis." 4. "The health care provider said if the muscle fibers were thickened, I would have polymyositis."

"I will know I have polymyositis if the muscle fibers are inflamed." In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is the opposite of what is noted in this disorder.

A nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction? 1. "I need to wear a MedicAlert bracelet." 2. "I need to purchase a travel kit that contains cortisone." 3. "I will need to take daily medications until my symptoms decrease." 4. "I need an increased dose of glucocorticoid medication during stressful minor illnesses."

"I will need to take daily medications until my symptoms decrease." Client teaching includes the need for lifelong daily medications. The client also is instructed to carry or wear a medical identification card or bracelet. A travel kit will need to be purchased. It should contain oral cortisone along with intramuscular preparations for self-injection and intravenous vials for emergency injection by a health care provider. Increased glucocorticoid dosage during stressful minor illnesses will be necessary.

A client has been hospitalized for an endocrine system dysfunction of the pancreas. The registered nurse asks the new orientee nurse what kind of problem a client hospitalized for endocrine dysfunction of the pancreas would expect. The new orientee nurse demonstrates understanding if which statement is made? 1. "Lipase levels will decrease." 2. "Insulin production will be decreased." 3. "There will be overproduction of trypsin." 4. "Amylase will be secreted in excess amounts."

"Insulin production will be decreased."

A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? 1. "What is it that you don't understand?" 2. "You can't always depend on your family to help." 3. "It's not really necessary for you to remember this." 4. "Let me go over the types of insulins with you again."

"Let me go over the types of insulins with you again." Reinforcement of knowledge and behaviors is vital to the success of the client's self-care. All of the other options do not address the need for client instructions and are not therapeutic responses.

Upon assessment of a child with a brain tumor, what will the nurse expect to hear the child say?

"My head hurts really bad in the morning.": Headache caused by increased intracranial pressure usually is worse in the morning and gradually improves during the day when the child is upright and venous drainage is enhanced. Like headache, vomiting occurs more commonly in the morning. Often it is not preceded by nausea and may become projectile, differing from a gastrointestinal disturbance in that the child may be ready to eat immediately after vomiting.

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis (DKA). Which assessment findings are consistent with this diagnosis? Select all that apply. 1. Polyuria 2. Polydipsia 3. Polyphagia 4. Dry mouth 5. Flushed, dry skin 6. Moist mucous membranes

1. Polyuria 2. Polydipsia 3. Polyphagia 4. Dry mouth 5. Flushed, dry skin Clinical manifestations of DKA include polyuria (frequent urination); polydipsia (excessive thirst); polyphagia (excessive hunger); dry mouth; and flushed, dry skin. The client with DKA experiences dehydration. Therefore, option 6 would not be noted.

A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. 1. Polyuria 2. Polydipsia 3. Concentrated urine 4. Complaints of excessive thirst 5. Specific gravity lower than 1.005

1. Polyuria 2. Polydipsia 4. Complaints of excessive thirst 5. Specific gravity lower than 1.005 A triad of clinical symptoms-polyuria, polydipsia, and excessive thirst-often occurs suddenly in the client with diabetes insipidus. The urine is dilute, with a specific gravity lower than 1.005, and the urine osmolality is low (50 to 200 mOsm/L).

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

1. Tremors 3. Irritability 4. Nervousness Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger.

A 45-year-old male complains of heartburn after eating and difficulty swallowing. He probably has:

Hiatal hernia Response Feedback: Regurgitation, dysphagia, and substernal discomfort after eating are common in individuals with hiatal hernia.

A client undergoing *hemodialysis* begins to experience *muscle cramping*. What is the best action by the hemodialysis nurse in this situation? 1. Administer hypotonic saline. 2. Increase the ultrafiltration rate. 3. Decrease the ultrafiltration rate. 4. Administer magnesium sulfate.

3 (► Muscle cramps during hemodialysis result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. ► The nurse corrects this situation by either slowing down the ultrafiltration rate on the hemodialyzer or administering hypertonic or isotonic normal saline. ► Magnesium sulfate is not prescribed to correct this occurrence.)

The nurse is creating a plan of care for a client with *chronic kidney disease and uremia*. The nurse is developing interventions to assist in promoting an increased dietary intake while at the same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care? 1. Increase the amount of protein in the diet. 2. Increase the amount of potassium in the daily diet. 3. Maintain a diet high in calories with frequent snacks. 4. Encourage the client to eat a large breakfast and smaller meals later in the day.

3 (► Uremia usually is accompanied by nausea, anorexia, and an unpleasant taste in the mouth. ► Most clients experience more nausea and vomiting in the morning. Therefore, to maintain optimal nutrition, it is best for these clients to eat a diet that is high in calories with frequent snacks and a light breakfast in the morning and larger meals later in the day. ► Dietary management usually is aimed at restricting protein, sodium, and potassium.)

A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. 1. Hypernatremia 2. Signs of water deficit 3. High urine osmolality 4. Low serum osmolality 5. Hypotonicity of body fluids 6. Continued release of antidiuretic hormone (ADH)

3. High urine osmolality 4. Low serum osmolality 5. Hypotonicity of body fluids 6. Continued release of antidiuretic hormone (ADH) SIADH is characterized by inappropriate continued release of ADH. This results in water intoxication, manifested as fluid volume expansion, hypotonicity of body fluids, and hyponatremia as a result of the high urine osmolality and low serum osmolality.

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? 1. Arterial insufficiency 2. Impaired venous return 3. Impaired arterial circulation 4. The presence of an infection

Impaired venous return Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast.

A client with epididymitis is upset about the *extent of scrotal edema*. *Attempts to reassure* the client that this condition is temporary have *not been effective*. The nurse should plan to address which client problem? 1. Pain related to fluid accumulation in the scrotum 2. Uneasiness related to inability to reduce scrotal swelling 3. Guilt related to the possibility of sterility secondary to scrotal swelling 4. Altered body appearance related to change in the appearance of the scrotum

4 (► Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. ► Pain may apply but does not correlate with the information in the question. ► There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern.)

A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. Intravenous opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

4, 5 (► Urolithiasis is the condition that occurs when a stone forms in the urinary system. ► Hydronephrosis develops when the stone has blocked the ureter and urine backs up and dilates and damages the kidney. ► Priority treatment is to allow the urine to drain and relieve the obstruction in the ureter. ► This is accomplished by placement of a percutaneous nephrostomy tube to drain urine from the kidney and placement of a ureteral stent to keep the ureter open. ► Peritoneal dialysis is not needed since the kidney is functioning. ► Stone analysis will be done later when the stone has been retrieved and analyzed. ► Opioid analgesics are necessary for pain relief but do not treat the obstruction.

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? 1. A platelet count of 200,000 mm3 (200 × 109/L) 2. A blood glucose level of 110 mg/dL (6.28 mmol/L) 3. A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) 4. A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values listed in the remaining options would not be noted in the client with Cushing's syndrome.

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? 1. It will drain fluid that has accumulated below the knee. 2. It is used to obtain a muscle biopsy for pathology studies. 3. It will determine the degree of range of motion of the joint. 4. It will identify if there is joint injury and provide a route for surgical repair if indicated.

It will identify if there is joint injury and provide a route for surgical repair if indicated. Arthroscopy is used to diagnose acute and chronic conditions of the joint. In addition, surgical repairs can be done during this procedure. This procedure does not quantitate the degree of range of motion of the joint. Obtaining a muscle biopsy is not performed through an arthroscope, nor is this invasive procedure necessary to remove fluid from below the knee.

Which of the following gastrointestinal (GI) clinical manifestations is subjective? (Select all that apply.)

Anorexia Nausea Response Feedback: Anorexia is lack of the desire for food intake and is a subjective experience. Nausea is a subjective experience. Retching is a forceful form of vomiting and is observable. Vomiting and diarrhea are observable.

The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action? 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches (15 cm) out to the side of the right foot

Moves the cane when the right leg is moved The cane is held on the stronger side to minimize stress on the affected extremity and to provide a wide base of support. The cane is held 4 to 6 inches (10 to 15 cm) lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through.

A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse plans to monitor for signs and symptoms of which hormone imbalance? 1. Growth hormone (GH) 2. Luteinizing hormone (LH) 3. Antidiuretic hormone (ADH) 4. Follicle-stimulating hormone (FSH)

Antidiuretic hormone (ADH) ADH is secreted by the posterior pituitary gland. The other hormone stored in the posterior pituitary gland is oxytocin. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. The anterior pituitary gland produces GH, LH, and FSH.

A client is treated in a health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? 1. Resting the foot 2. Applying a heating pad 3. Applying an elastic compression bandage 4. Elevating the ankle on a pillow while sitting or lying down

Applying a heating pad Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.

The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? 1. Assess the client's cognitive level. 2. Assess the temperature of the cast. 3. Monitor for the presence of drainage or odors on or beneath the cast. 4. Assess capillary refill, temperature, color, and amount of pain in the right hand.

Assess capillary refill, temperature, color, and amount of pain in the right hand. The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.

The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction? 1. Bends over to tie shoes 2. Sits in a recliner with feet elevated 3. Squats to pick up an item from the floor 4. Sleeps in a side-lying position with knees and hips bent

Bends over to tie shoes To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking up things or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.

A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse should expect which electrolyte abnormality? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

Calcium The C cells of the thyroid gland are helpful in maintaining normal plasma calcium levels. They do not affect the levels of sodium, potassium, or magnesium.

A 54-year-old male complains that he has been vomiting blood. Tests reveal portal hypertension. Which of the following is the most likely cause of his condition?

Cirrhosis of the liver Response Feedback: Portal hypertension occurs secondarily to cirrhosis of the liver.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear. 4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.

Convey empathy, trust, and respect toward the client. Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur.

A 55-year-old male intravenous (IV) drug user with a history of advanced liver disease is diagnosed with hepatorenal syndrome. Which of the following clinical manifestations would be expected?

Oliguria Jaundice Ascites Anorexia Oliguria and complications of advanced liver disease, including jaundice, ascites, and GI bleeding, are usually present. Systolic blood pressure is usually below 100 mm Hg. Nonspecific symptoms of hepatorenal syndrome include anorexia, weakness, and fatigue.

A 46-year-old female is diagnosed with gastric ulcers. Which of the following characterizes the disorder?

Pain occurs immediately after eating. Duration of treatment is extended. The pattern of pain is different from that of duodenal ulcers as it frequently occurs immediately after eating. Gastric ulcers cause more anorexia, vomiting, and weight loss than duodenal ulcers. Gastric ulcers also tend to be chronic rather than alternating between periods of remission and exacerbation. The evaluation and treatment of gastric ulcers are similar to the evaluation and treatment of duodenal ulcers, although duration of treatment is longer than with duodenal ulcers.

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2. Place a draw sheet on the mattress for pulling the client up in bed. 3. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 4. Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning.

Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed frame for the client's use. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote repositioning by the client. Encouraging the client to push with the unaffected leg on the bed mattress for repositioning may cause skin breakdown on the unaffected heel area.

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? 1. Presence of fasciculations 2. Muscle strength of normal power 3. Symmetrical movements bilaterally 4. Hypertrophy of right upper arm of 1 cm

Presence of fasciculations Fasciculations are fine-muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.

A test to measure long-term control of diabetes mellitus has been prescribed for a client. In instructing the client about the test, the nurse explains that long-term control can be measured because chronic high blood glucose levels lead to irreversible glucose binding onto what? 1. Platelets 2. Muscle tissue 3. Adipose tissue 4. Red blood cells (RBCs)

Red blood cells (RBCs) With chronic high circulating blood glucose levels, some glucose binds irreversibly onto RBCs and remains there for the life of the cell. The average life span of an RBC is 120 days. The measurement of glycosylated hemoglobin A (HbA1c), which detects glucose binding on the RBC membrane, is expressed as a percentage. Glucose does not bind onto platelets in diabetes mellitus. One of the problems in diabetes is that muscle and adipose cells may be unable to transport glucose across cell membranes.

During health history taking, the client complains of weight loss and diarrhea and says that he can "feel my heart beating in my chest." The nurse anticipates that which diagnostic test will most likely be prescribed by the health care provider (HCP) in order to determine the underlying condition leading to the client's signs and symptoms? 1. Endoscopy 2. Electrocardiogram 3. Stool for occult blood 4. Serum thyroid-stimulating hormone (TSH)

Serum thyroid-stimulating hormone (TSH) A client with increased activity of the thyroid gland exhibits weight loss as a result of the higher metabolic rate, increased frequency of bowel movements or diarrhea, and an increased pulse rate, which account for the client's complaint of feeling his heart beating in his chest. Therefore, a TSH level should be drawn to validate hyperthyroidism. The TSH level will be decreased in hyperthyroid states.

The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? 1. Shortening and abduction 2. Abduction and internal rotation 3. Shortening and internal rotation 4. Shortening and external rotation

Shortening and external rotation Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.

A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? 1. Fever, bradycardia 2. Fever, hypertension 3. Tachycardia, hypotension 4. Bradycardia, hypertension

Tachycardia, hypotension Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and, in the case of a fractured femur, into the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? 1. The client moves both crutches forward and then swings both feet forward to the crutches. 2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 3. The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. 4. The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.

The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. In a three-point gait the client is instructed to simultaneously move both crutches and the affected leg forward and then to move the unaffected leg forward. Option 1 identifies a swing-through gait. Options 3 and 4 identify a four-point gait.

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? 1. Thyroid 2. Pituitary 3. Parathyroid 4. Adrenal cortex

Thyroid The thyroid gland is responsible for a number of metabolic functions in the body. Among these are metabolism of nutrients such as fats and carbohydrates. Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. A client with increased activity of the thyroid gland will experience weight loss from the higher metabolic rate and will have an increased pulse rate. The anterior pituitary gland produces growth hormone, luteinizing hormone, and follicle-stimulating hormone. Antidiuretic hormone (ADH) and oxytocin are secreted by the posterior pituitary gland. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

A client has been diagnosed with Cushing's syndrome. The nurse should assess the client for which expected manifestations of this disorder? 1. Dizziness 2. Weight loss 3. Hypoglycemia 4. Truncal obesity

Truncal obesity The client with Cushing's syndrome may exhibit a number of different manifestations. These may include moon face, truncal obesity, and a "buffalo hump" fat pad. Other signs include hyperglycemia, hypernatremia, hypocalcemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infants ability to suck and grasp the mothers finger. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

a. Reflexes Questions regarding reflexes include such questions as, What have you noticed about the infants behavior, Are the infants sucking and swallowing seem coordinated, and Does the infant grasp your finger? The other responses are incorrect.

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diet. Which statement, if made by the client, indicates a need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I'll snack on fruit instead of cake." 4. "I need to purchase special dietetic foods."

"I need to purchase special dietetic foods." It is important to emphasize to the client and family that they are not eating a diabetic diet but rather a balanced meal plan. Adherence to nutritional principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or swelling to my health care provider."

"I need to report a fever or swelling to my health care provider." After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider.

A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder? 1. Diabetes mellitus 2. Orthostatic hypotension 3. Coronary artery disease 4. Intravenous (IV) contrast medium

1 (► Pyelonephritis is most commonly caused by entry of bacteria, obstruction, or reflux. ► Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, overuse of analgesics, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.)

A client with renal cancer is being treated preoperatively with *radiation therapy*. What statement by the client demonstrates understanding of proper care of the skin over the treatment field? 1. "I need to avoid skin exposure to direct sunlight and chlorinated water." 2. "I need to use lanolin-based cream on the affected skin on a daily basis." 3. "I need to use the hottest water possible to wash the treatment site twice daily." 4. "I need to remove the lines or ink marks using a gentle soap after each treatment."

1 (► The client undergoing radiation therapy should avoid washing the site until instructed to do so. ► The client should then wash, using mild soap and warm or cool water, and pat the area dry. ► No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. ► Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. ► The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water as from swimming pools.)

The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1. Maintain strict aseptic technique. 2. Add heparin to the dialysate solution. 3. Change the catheter site dressing daily. 4. Monitor the client's level of consciousness.

1 (► The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. ► Although changing the catheter site dressing daily may assist in preventing infection, this option relates to an external site. ► Adding heparin to the dialysate solution and monitoring the client's level of consciousness are unrelated to the major complication of peritoneal dialysis.)

The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation? 1. Fever 2. Fatigue 3. Clear dialysate output 4. Leaking around the catheter site

1 (► The signs of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. ► Fatigue may be associated with peritonitis, but fever is the most likely sign. ► Leaking around the catheter site is not an indication of peritonitis.)

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. 1. Acknowledge the client's feelings. 2. Assess the client and family's coping patterns. 3. Explore the meaning of the illness with the client. 4. Set limits on mood swings and expressions of hostility. 5. Give the client information when the client is ready to listen.

1, 2, 3, 5 (► Clients with ESRD are likely to experience mood swings or express hostility, anger, and depression, among other responses. ► The nurse should acknowledge the client's feelings, allow the client to express those feelings, and be supportive. ► Options 1, 2, 3, and 5 are helpful and appropriate interventions for the client. ► Setting limits for this client is not client focused, does not allow the client to express concerns, and is nontherapeutic in this situation.)

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. 1. Agitation 2. Euphoria 3. Depression 4. Withdrawal 5. Labile emotions

1, 3, 4, 5 (► The client with CKD often experiences a variety of psychosocial changes. ► These changes are related to uremia and to the stress associated with living with a chronic disease that is life threatening. ► Euphoria is not part of the clinical picture for the client in renal failure. ► Clients with CKD may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur.)

The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. 1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4. Observe the client for dizziness during ambulation and report immediately. 5. Understand that the client may experience nausea as a normal expectation during ambulation.

1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4. Observe the client for dizziness during ambulation and report immediately. When delegating the task of ambulation to a UAP, the nurse should ensure that the UAP understands instructions before ambulation, including making sure that clutter is removed in the area of ambulation; assisting the client in applying nonskid socks before ambulation; instructing the client to sit up on the bedside and dangle before ambulation; and observing the client for dizziness and reporting this finding immediately. The client should not experience nausea, dizziness, or diaphoresis or become pale during ambulation under normal conditions.

Which findings should raise suspicion to the nurse that a head-injured client may be experiencing diabetes insipidus? Select all that apply. 1. Urine specific gravity is 1.001. 2. Ketones are present in the urine. 3. Jugular venous distention is observed. 4. Serum osmolality is 320 mOsm/kg (320 mmol/kg) of water. 5. Blood glucose levels are greater than 200 mg/dL (11.4 mmol/L). 6. Urine output has increased from 1000 mL in 24 hours to 4000 mL in 24 hours.

1. Urine specific gravity is 1.001. 4. Serum osmolality is 320 mOsm/kg (320 mmol/kg) of water. 6. Urine output has increased from 1000 mL in 24 hours to 4000 mL in 24 hours. Signs of diabetes insipidus include low urine specific gravity (<1.005), high serum osmolality (>300 mOsm/kg of water), and increased urine output from a deficiency of antidiuretic hormone (ADH). Options 2, 3, and 5 are not characteristic of diabetes insipidus.

A client with benign prostatic hyperplasia (BPH) undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome? 1. Tachycardia and diarrhea 2. Bradycardia and confusion 3. Increased urinary output and anemia 4. Decreased urinary output and bladder spasms

2 (► Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. ► The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting)

A client has urinary calculi composed of uric acid. The nurse is teaching the client dietary measures to prevent further development of uric acid calculi. The nurse should inform the client that it is acceptable to consume which item? 1. Steak 2. Shrimp 3. Chicken liver 4. Cottage cheese

4 (► With a uric acid stone, the client should limit intake of foods high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. ► Intake of foods with moderate levels of purines, such as red and white meats and some seafood, also is limited. ► Avoiding the consumption of milk and dairy products is a recommended dietary change for calculi composed of calcium stones but is acceptable for the client with a uric acid stone.)

An increase in the rate of red blood cell breakdown causes which form of jaundice?

Hemolytic Response Feedback: Excessive hemolysis (breakdown) of red blood cells can cause hemolytic jaundice (prehepatic jaundice).

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Make sure that the knots are at the pulleys. 2. Inspect the skin under the boot at least every 8 hours. 3. Make sure the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to be sure that they are resting on a firm surface.

Inspect the skin under the boot at least every 8 hours. When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device for skin irritation and breakdown. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

A client has overactivity of the thyroid gland. The nurse should expect which finding? 1. Weight gain 2. Nutritional deficiencies 3. Low blood glucose levels 4. Increased body fat stores

Nutritional deficiencies Although the client may experience an increased appetite with overactivity of the thyroid gland, food intake does not meet energy demands, and nutritional deficiencies can develop. Weight loss occurs as a result of the increased metabolic activity. Glucose tolerance is decreased, and the client experiences hyperglycemia. Overactivity of the thyroid gland also causes increased metabolism, including fat metabolism. This leads to decreased levels of fat in the bloodstream, including cholesterol, and decreased body fat stores.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6°F (38.7°C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

Temperature of 101.6°F (38.7°C) orally The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported.

The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment? 1. The hip 2. The knee 3. The ankle 4. The great toe

The knee A meniscus is an interarticular fibrocartilage that partially or completely separates the components of a joint. The knee is a common area for meniscal tears because it is frequently injured as a result of falls and sports injuries; therefore, options 1, 3, and 4 are incorrect.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for follow-up care

The need for sensory stimulation A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention? 1. To have the cast bivalved 2. To have a window cut in the cast 3. To have the cast replaced with an air splint 4. To have extra padding put over this area of the cast

To have a window cut in the cast A window may be cut in a dried cast to relieve pressure in an area of a bony prominence, to assess pulses, to relieve discomfort, or to remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking radiographs, or to make a half-cast for use as an intermittent splint. The use of an air splint is not indicated. Padding is not placed on top of a cast.

The nurse determines that a client's skeletal traction needs correction if which observation is made? 1. Weights are not touching the floor. 2. Weights are hanging free of the bed. 3. Traction ropes rest against the footboard. 4. Traction ropes are aligned in each pulley.

Traction ropes rest against the footboard. Traction ropes must hang free of the bed. The remaining options are observations that indicate correct use of the traction setup.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL (2.25 mmol/L) 2. Uric acid level of 9.0 mg/dL (0.54 mmol/L) 3. Potassium level of 4.1 mEq/L (4.1 mmol/L) 4. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

Uric acid level of 9.0 mg/dL (0.54 mmol/L) In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL (0.48 mmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L) and for a female, from 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.

When performing an external genitalia examination of a 10-year-old girl, the nurse notices that no pubic hair has grown in and the mons and the labia are covered with fine vellus hair. These findings are consistent with stage _____ of sexual maturity, according to the Sexual Maturity Rating scale. a. 1 b. 2 c. 3 d. 4

a. 1 Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair, and the mons and labia are covered with fine, vellus hair as on the abdomen (see Table 26-1).

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a. Dysuria. b. Nocturia. c. Polyuria. d. Hematuria.

a. Dysuria. Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis. Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood in the urine.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

a. Frontal The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would: a. Squeeze the glans to check for the presence of discharge. b. Consider this finding as normal, and proceed with the examination. c. Assess the testicles for the presence of masses or painless lumps. d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has noticed.

b. Consider this finding as normal, and proceed with the examination. After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles and appears corrugated.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one very sharp prick. What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

b. This response is most likely the result of the summation effect. At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: a. Uterine prolapse, graded first degree. b. Uterine prolapse, graded second degree. c. Uterine prolapse, graded third degree. d. A normal finding.

b. Uterine prolapse, graded second degree. The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degreethe cervix appears at the introitus with straining; second degreethe cervix bulges outside the introitus with straining; and third degreethe whole uterus protrudes, even without straining (essentially, the uterus is inside out).

The __ coordinates movement, maintains equilibrium, and helps maintain posture. a. extrapyramidal system b. cerebellum c. upper and lower motor neurons d. basal ganglia

b. cerebellum The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., posture balance of the body), and muscle tone. The extrapyramidal system maintains muscle tone and controls body movements, especially gross automatic movements such as walking. The upper motor neurons are located within the central nervous system; influence or modify the lower motor neurons; and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves. The basal ganglia control automatic associated movements of the body.

During the interview with a female patient, the nurse gathers data that indicate the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? a. I have noticed that my muscles ache at night when I go to bed. b. I will be very happy when I can stop worrying about having a period. c. I have been noticing that I sweat a lot more than I used to, especially at night. d. I have only been pregnant twice, but both times I had breast tenderness as my first symptom.

c. I have been noticing that I sweat a lot more than I used to, especially at night.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

c. Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, Have you noticed any: a. Changes in your urination patterns? b. Excessive vaginal bleeding? c. Unusual vaginal discharge or itching? d. Changes in your desire for intercourse?

c. Unusual vaginal discharge or itching?

When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. c. Genital herpes. d. Genital warts.

d. Genital warts. The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grapelike clusters. (See Table 24-4 for more information and for the descriptions of the other options.)

A client who is performing peritoneal dialysis at home calls the clinic and reports that the *outflow* from the *dialysis catheter* seems to be *decreasing* in amount. The clinic nurse should ask which question first? 1. "Have you had any diarrhea?" 2. "Have you been constipated recently?" 3. "Have you had any abdominal discomfort?" 4. "Have you had an increased amount of flatulence?"

2 (► Reduced outflow from the dialysis catheter may be caused by the catheter position, infection, or constipation. ► Constipation may contribute to a reduced outflow because peristalsis seems to aid in drainage. ► Options 1, 3, and 4 are unrelated to the causes of reduced outflow from the dialysis catheter.)

A 52-year-old presents with bleeding from the rectum. This condition is referred to as:

Hematochezia (Response Feedback: Hematochezia is bleeding from the rectum.)

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information should the nurse provide regarding the hemodialysis schedule? 1. 5 hours of treatment 2 days per week 2. 2 hours of treatment 6 days per week 3. 3 to 4 hours of treatment 3 days per week 4. 2 to 3 hours of treatment 5 days per week

3 (► The typical schedule for hemodialysis is 3 to 4 hours of treatment 3 days per week. ► Individual adjustments are made according to variables such as the size of the client, type of dialyzer, rate of blood flow, personal client preferences, and other factors.)

A 16-year-old female is diagnosed with anorexia nervosa. By definition, the patient would weigh ____% less than normal for age and height:

15

The nurse teaches a parent of an infant diagnosed with myelomeningocele about the disorder. Which statement, made by the parent, indicates successful teaching?

"It is common for visual problems to occur."

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan? 1. Soak the feet in hot water. 2. Avoid using a mild soap on the feet. 3. Always have a podiatrist cut the toenails. 4. Apply a moisturizing lotion to dry feet but not between the toes.

Apply a moisturizing lotion to dry feet but not between the toes. The client is instructed to use a moisturizing lotion on the feet and avoid applying lotion between the toes. The client should be instructed not to soak the feet and should avoid hot water to prevent burns. The client should be instructed to wash the feet daily with a mild soap. The client may cut the toenails straight across and even with the toe itself and would consult a podiatrist if the toenails are thick or hard to cut or if vision is poor.

During a teaching session with the staff, the nurse shares that during gestation the brain's growth of migration occurs during which time frame?

At 3 to 6 months

What is the pathology behind West syndrome in children?

Central nervous system insult

Which term should the nurse use to describe the structure that develops into the nervous system?

Embryonic ectoderm

The most common clinical manifestation of portal hypertension is _____ bleeding.

Esophageal Response Feedback: Vomiting of blood from bleeding esophageal varices is the most common clinical manifestation of portal hypertension.

What is the age of onset for progressive cerebellar ataxia in children?

Later childhood

An infant has lysosomal storage disease. Which type of metabolism is most affected?

Lipid

The cardinal sign of pyloric stenosis caused by ulceration or tumors is:

Vomiting The cardinal sign of pyloric stenosis is vomiting

A 40-year-old female presents complaining of pain near the midline in the epigastrium. Assuming the pain is caused by a stimulus acting on an abdominal organ, the pain felt is classified as:

Visceral (Response Feedback: Visceral pain arises from a stimulus (distention, inflammation, ischemia) acting on an abdominal organ.)

The cardinal signs of small bowel obstruction are:

Vomiting and distention Response Feedback: Colicky pains followed by vomiting and distention are the cardinal symptoms of small bowel obstruction.

A client who visits the health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse should check for which manifestations? 1. Weight loss and thinning skin 2. Complaints of weakness and lethargy 3. Diaphoresis and increased hair growth 4. Increased heart rate and respiratory rate

Complaints of weakness and lethargy Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? 1. Shakiness 2. Increased thirst 3. Profuse sweating 4. Decreased urine output

Increased thirst The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition.

Reflux esophagitis is defined as a(n)

Inflammatory response to gastroesophageal reflux Response Feedback: When gastroesophageal reflux leads to an inflammatory response, it is termed reflux esophagitis.

A child presents with congenital hydrocephalus. When the nurse taps on the child's skull, a resonant sound is heard. How should the nurse document this finding?

Macewen sign present

What is a sign of spina bifida occulta in a child?

No visible sign: It is possible for a defect to occur without any visible exposure of meninges or neural tissue and the term spina bifida occulta is then used. A subcutaneous mass is seen in spina bifida but not in spina bifida occulta. In spina bifida occulta, there is no visible exposure of meninges or neural tissue. Therefore a dimple in the midline is not a sign of spina bifida occulta. Hair along the length of the spine is a sign of spina bifida, not spina bifida occulta.

The primary causes of duodenal ulcers include (select all that apply):

Nonsteroidal anti-inflammatory drugs (NSAIDs) H. pylori infection Infection with H. pylori and chronic use of NSAIDs are the major causes of duodenal ulcer. Consuming spicy foods, trauma, and antibiotics do not lead to duodenal ulcer disease.

A 38-year-old female complains of epigastric fullness following a meal, nausea, and epigastric pain. Tests reveal narrowing of the opening between the stomach and the duodenum. This condition is referred to as:

Pyloric obstruction Response Feedback: The pylorus is the opening between the esophagus and the duodenum; the obstruction is pyloric.

A 52-year-old patient states that when she sneezes or coughs she wets herself a little. She is very concerned that something may be wrong with her. The nurse suspects that the problem is: a. Dysuria. b. Stress incontinence. c. Hematuria. d. Urge incontinence.

b. Stress incontinence.

During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Enlarged scrotal sac. b. Increased pubic hair. c. Decreased penis size. d. Increased rugae over the scrotum.

c. Decreased penis size. In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae over the scrotal sac decreases. The scrotal sac does not enlarge.

__________________ is an emergency requiring surgery. a. A scrotal hernia b. Epididymitis c. Testicular torsion d. Cryptorchidism

c. Testicular torsion Testicular torsion is a sudden twisting of the spermatic cord; blood supply is cut off, and the testis can become gangrenous in a few hours. Emergency surgery is required. A scrotal hernia is usually due to indirect inguinal hernia; the scrotal sac herniates through the internal inguinal ring and passes into the scrotum. Epididymitis is an acute infection of the epididymis. Cryptorchidism is a developmental defect in which the testes have not descended.

The most common sexually transmitted infection in the United States is: a. gonorrhea. b. syphilis. c. chlamydia. d. trichomoniasis.

c. chlamydia. Chlamydia is the most common sexually transmitted infection in the United States.

The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? 1. "The cast will give off heat as it dries." 2. "I can bear weight on the cast in one-half hour." 3. "The cast edges may be trimmed with a cast knife." 4. "A stockinette will be placed over the leg area to be casted."

"I can bear weight on the cast in one-half hour." A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours, depending on the nature and thickness of the cast. A plaster cast gives off heat as it dries. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed.

A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if he or she makes which statement? 1. "I need to soak the skin and wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if exposed to the sun for a period of time."

"I need to scrub the skin vigorously with soap and water." The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. People often want to scrub the dead skin away, but scrubbing irritates the skin and should not be done. The client should avoid overexposing the skin to the sunlight.

A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? 1. "I should place hot packs on my ankle." 2. "I should wrap my ankle with blankets." 3. "I should elevate my foot above the level of the heart." 4. "I should try to ambulate at least 10 minutes out of every hour."

"I should elevate my foot above the level of the heart." Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.

The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? 1. "I will check my blood glucose level every day at 5:00 p.m." 2. "I will check my blood glucose level 1 hour after each meal." 3. "I will check my blood glucose level 2 hours after each meal." 4. "I will check my blood glucose level before each meal and at bedtime."

"I will check my blood glucose level before each meal and at bedtime. The most effective and accurate measure for testing blood glucose is to test the level before each meal and at bedtime. If possible and feasible, testing should be done during the nighttime hours. Checking the level after the meal will provide an inaccurate assessment of diabetes control. Checking the level once daily will not provide enough data to control the diabetes mellitus.

The nurse teaches a parent of a child who is diagnosed with a neuroblastoma about clinical manifestations of the disorder. Which statement, made by the parent, indicates successful learning?

"It is most common for these tumors to cause weight loss."

The nurse teaches the mother of a newborn about the fontanelles or "soft spots." Which statement, made by the mother, indicates successful teaching?

"Soft spots can be used to detect excess fluid in the brain."

A client with uric acid calculi is placed on a low-purine diet. The nurse instructs the client to restrict the intake of which food? 1. Fish 2. Plum juice 3. Fruit juice 4. Cranberries

1 (► Clients who form uric acid calculi should be placed on a low-purine diet. Their intake of fish and meats (especially organ meats) should be restricted. ► Dietary modifications also may help adjust urinary pH so that stone formation is inhibited. ► Depending on health care provider prescription, the urine may be alkalinized by increasing the intake of bicarbonates or acidified by drinking cranberry, plum, or prune juice.)

The nurse has provided dietary instructions to a client with renal calculi who must learn about the foods that yield an alkaline residue in the urine. The nurse determines that education was effective if the client chooses which selections from a diet menu? 1. Spinach salad, milk, and a banana 2. Chicken, potatoes, and cranberries 3. Peanut butter sandwich, milk, and prunes 4. Linguini with shrimp, tossed salad, and a plum

1 (► In some client situations, the health care provider may prescribe a diet that consists of foods that yield either an alkaline or an acid residue in the urine. ► In an alkaline residue diet, all fruits are allowed except cranberries, blueberries, prunes, and plums. ► Options, 2, 3 and 4 represent an acid residue diet.)

A client with chronic kidney disease (CKD) is being managed by continuous ambulatory peritoneal dialysis (CAPD). During outflow, the nurse notes that only half of the 2-L dialysate has returned and the flow has stopped. Which interventions should the nurse take to enhance the outflow? Select all that apply. 1. Reposition the client. 2. Encourage a low-fiber diet. 3. Make sure the peritoneal catheter is not kinked. 4. Slide the peritoneal catheter farther into the abdomen. 5. Check that the drainage bag is lower than the client's abdomen. 6. Assess the stool history, and institute elimination measures if the client is constipated.

1, 3, 5, 6

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions should the nurse include in the plan to prevent complications of the surgery? Select all that apply. 1. Keep the leg slightly abducted. 2. Teach leg exercises to the client. 3. Use aseptic technique for wound care. 4. Prevent hip flexion beyond 90 degrees. 5. Keep the client's knees flexed whenever the client is in bed. 6. Massage the legs daily to increase circulation and venous return

1. Keep the leg slightly abducted. 2. Teach leg exercises to the client. 3. Use aseptic technique for wound care. 4. Prevent hip flexion beyond 90 degrees. A total hip arthroplasty (THA) is also known as a total hip replacement (THR). Postoperative complications can include dislocation, infection, venous thromboembolism, hypotension, bleeding, and infection. To prevent dislocation, the nurse needs to position the client correctly with the leg slightly abducted and prevent hip flexion beyond 90 degrees. Signs of dislocation such as acute pain, rotation, and extremity shortening needs to be reported immediately to the surgeon. To prevent infection the nurse needs to perform thorough handwashing and use aseptic technique for wound care and emptying of drains. To prevent venous thromboembolism, the client would wear elastic stockings and/or a sequential compression device per agency policy and surgeon prescription. The nurse would encourage fluid intake and teach the client leg exercises to promote circulation. Legs are not massaged; in addition, knee flexion is avoided for a prolonged period of time because these actions promote venous stasis and thromboembolism. The nurse would monitor vital signs at least every 4 hours and observe the client for bleeding. Any signs of complications are reported immediately to the surgeon.

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 4. Ambulation with a walker 5. Antiinflammatory medications

1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 5. Antiinflammatory medications The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, antiinflammatory medications, rest, ice, and possibly reconstructive surgery.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

1. Polyuria 3. Bone pain The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

A client has undergone a 2-hour oral glucose tolerance test (OGTT). Which of the listed glucose levels is compatible with diabetes mellitus at the conclusion of the test? 1. 80 mg/dL (4.57 mmol/L) 2. 110 mg/dL (6.0 mmol/L) 3. 130 mg/dL (7.42 mmol/L) 4. 160 mg/dL (9.14 mmol/L)

160 mg/dL (9.14 mmol/L) The normal reference values for OGTTs are lower than 140 mg/dL (8 mmol/L) at 120 minutes; lower than 200 mg/dL (11.4 mmol/L) at 30, 60, and 90 minutes; and lower than 115 mg/dL (6.57 mmol/L) in the fasting state. A glucose level of 160 mg/dL (9.14 mmol/L) is higher than the normal reference range, so therefore is the correct answer.

The nurse is performing an assessment on a client after a cystoscopy. Which assessment finding indicates a need to notify the health care provider (HCP)? 1. A temperature of 99.4°F (37.4°C) 2. Grossly bloody urine with clots 3. A bluish or green tinge to the urine 4. A blood pressure of 120/82 mm Hg

2 (► Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the HCP immediately. ► The client may have clear or blood-tinged urine after cystoscopy. ► If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. ► A blood pressure of 120/82 mm Hg and a temperature of 99.4°F (37.4°C) are not abnormal findings at this time.)

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1. Ice 2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction

2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.

Which tests can be used to diagnose gout? Select all that apply. 1. Renal ultrasound 2. Serum uric acid level 3. Bone marrow biopsy 4. Urinalysis with culture 5. Synovial fluid aspiration 6. 24-hour urine uric acid level

2. Serum uric acid level 5. Synovial fluid aspiration 6. 24-hour urine uric acid level Diagnostic tests for gout include serum uric acid level and 24-hour urine uric acid level, as well as synovial fluid aspiration and x-ray of the affected areas. Renal ultrasound, bone marrow biopsy, and urinalysis with culture are not specifically associated with gout; they test for a variety of other conditions.

A home care nurse is making home visits to an older client with urinary incontinence who is very concerned about the incontinent episodes. Which finding by the nurse indicates that the client has an environmental barrier to normal voiding? 1. Presence of hand railings in the bathroom 2. Having 1 bathroom on each floor of the home 3. Bathroom located on the second floor, bedroom on the first floor 4. Night light present in the hall between the bedroom and bathroom

3 (► Having the bathroom on the second floor and the bedroom on the first floor may pose a problem for the older client with incontinence. ► The need to negotiate the stairs and the distance both may interfere with reaching the bathroom in a timely fashion. ► It is more helpful to the incontinent client to have a bathroom on the same floor as the bedroom or to have a commode rented for use. ► Hand railings and night lights are helpful to the client in reaching the bathroom quickly and safely.)

The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? 1. Decreases the risk of peritonitis 2. Prevents disequilibrium syndrome 3. Increases osmotic pressure to produce ultrafiltration 4. Prevents excess glucose from being removed from the client

3 (► Increasing the glucose concentration makes the solution more hypertonic. ► The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange. ► The remaining options do not identify the purpose of the glucose.)

The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? 1. Anxiety 2. Memory deficits 3. Presence of family 4. Short attention span

3 (► The client with CKD may have several barriers to learning. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. ► Anxiety about the disease and its ramifications frequently interferes with learning. ► Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. ► Mental functioning usually improves once hemodialysis has begun.)

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulses present and with swollen, pink fingers 3. Client report of severe, deep, unrelenting pain 4. Client report of pain as nurse assesses finger movement 5. Client report of numbness and tingling sensation in the fingers

3. Client report of severe, deep, unrelenting pain 4. Client report of pain as nurse assesses finger movement 5. Client report of numbness and tingling sensation in the fingers The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.

A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. Which is the most appropriate nursing action to prevent complications of this procedure? 1. Monitor urine output once per shift. 2. Measure specific gravity once per shift. 3. Encourage an excessive intake of oral fluids. 4. Ensure that the catheter tubing is not kinked.

4 (► A complication after surgical repair of the bladder is disruption of sutures, caused by tension on them from urine buildup. ► The nurse prevents this from happening by ensuring that the catheter is able to drain freely. ► This involves basic catheter care, including keeping the tubing free from kinks, maintaining the tubing at a level below the bladder, and monitoring the flow of urine frequently. ► Monitoring of urine output every shift is insufficient to detect decreased flow from catheter kinking. ► Measurement of urine specific gravity and an excessive intake of oral fluids do not prevent complications of bladder surgery.)

A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed surgically for hemodialysis. Which action is most appropriate for the nurse to document in the plan for care of the AV fistula? 1. Palpate the bruit of the AV fistula weekly to assess for thrombosis. 2. Use the AV fistula site for blood draws to prevent increased pain of multiple blood draws. 3. Take the blood pressure readings in the extremity with the AV fistula to get a more accurate reading. 4. Teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis.

4 (► An AV fistula is a vascular access system that is required for hemodialysis. ► It is a device established for clients who need long-term hemodialysis. ► It is created by connecting an artery to a vein inside the body to create a vessel that can handle the amount of blood flow necessary for effective dialysis. ► Bleeding, clotting, and infection are risks with all vascular devices. ► It also is very important to avoid any activity that would promote the status of blood or increase the risk for infection. ► Taking the blood pressure in the affected arm, carrying heavy objects in the arm, and lying on the arm at night could increase the risk for clotting in the fistula. ► To check circulation of the fistula, the nurse should palpate or feel for the thrill or auscultate (listen with a stethoscope) for the bruit. It is important to do this at least daily to ascertain the patency of the fistula. ► To avoid infection, that extremity is never used for peripheral intravenous access (placement of an intravenous line) or for blood draws. ► Strict aseptic technique is used in accessing the fistula for dialysis.)

A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention? 1. Check the shunt for the presence of bruit and thrill. 2. Observe the site once during the shift as time permits. 3. Check the results of the prothrombin time as they are determined. 4. Ensure that small clamps are attached to the arteriovenous shunt dressing.

4 (► An external arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because 2 ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. ► If accidental disconnection occurs, the client could lose blood rapidly. ► For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. ► The shunt site also should be assessed at least every 4 hours. ► Checking the shunt for the presence of bruit and thrill relates to patency of the shunt. ► Although checking the results of the prothrombin time is important, it is not the priority nursing action.)

A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states that he or she will take which action? 1. Use latex condoms to prevent disease transmission. 2. Return to the clinic as requested for follow-up culture in 1 week. 3. Reduce the chance of reinfection by limiting the number of sexual partners. 4. Take an antibiotic so as to prophylactically prevent symptoms of Chlamydia.

4 (► Antibiotics are not taken prophylactically to prevent acquisition of chlamydial infection. ► The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms. ► In some cases, follow-up culture is requested in 4 to 7 days to confirm a cure. ► The remaining options are correct measures.)

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine

4 (► Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. ► The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. ► If untreated, complete obstruction and urinary retention can occur. ► Constipation or scrotal edema is not associated with benign prostatic hyperplasia.)

The nurse assessing the ureterostomy of a postoperative client interprets that the stoma has normal characteristics if which is observed? 1. Dry 2. Pale 3. Dark-colored 4. Red and moist

4 (► Following ureterostomy, the stoma should be red and moist. ► A dry stoma may indicate fluid volume deficit. ► A pale stoma may indicate an inadequate vascular supply. ► Any darkness or duskiness of the stoma may mean loss of vascular supply and must be corrected immediately to prevent necrosis.)

The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? 1. Potassium 2. Creatinine 3. Phosphorus 4. Red blood cell (RBC) count

4 (► Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. ► Hemodialysis also worsens anemia because RBCs are lost during dialysis from blood sampling and anticoagulation and from residual blood left in the dialyzer. ► Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.)

The nurse is admitting a client who has an arteriovenous (AV) fistula in the right arm for hemodialysis. Which nursing intervention is the best way to prevent injury to the AV site? 1. Putting a large note about the access site on the front of the medical record 2. Applying an allergy bracelet to the right arm, indicating the presence of the fistula 3. Telling the client to inform all caregivers who enter the room about the presence of the access site 4. Placing a sign at the bedside that reads "No blood pressure measurements or venipunctures in the right arm"

4 (► No venipunctures or blood pressure measurements should be performed in a limb with a hemodialysis access device. ► This commonly is communicated to all caregivers by placing a sign at the client's bedside. ► Placing a note on the front of the medical record does not ensure that everyone caring for the client is aware of the access device. ► An allergy bracelet is placed on the client with an allergy. ► The client should not be assigned the responsibility for informing caregivers. ► Some agencies use special bracelets for clients with an AV fistula to alert health care providers. Agency guidelines should always be followed in the care of the client.)

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? 1. Skin atrophy 2. The presence of sunken eyes 3. Drooping on 1 side of the face 4. A rounded "moonlike" appearance to the face

A rounded "moonlike" appearance to the face With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin. The remaining options are not associated with the assessment findings in Cushing's syndrome

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1. A 25-year-old woman who runs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes

A sedentary 65-year-old woman who smokes cigarettes Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.

A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? 1. The surgeon 2. A social worker 3. The physical therapist 4. The clinical nurse specialist

A social worker After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional can provide the most helpful information about resources available to the client. The clinical nurse specialist and the surgeon do not have information related to financial resources. The physical therapist has the best knowledge of techniques for increasing mobility and endurance.

A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? 1. A walker 2. A wooden crutch 3. A straight leg cane 4. A Lofstrand crutch

A straight leg cane A straight leg cane is useful for the client with slight weakness in one leg. A walker is beneficial to the client with greater or bilateral weakness or one who is at risk for falls. Wooden crutches often are used by clients with a leg cast. Lofstrand crutches aid clients who need crutches but have limited arm strength.

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze

Abductor splint After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.

The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? 1. Elevating the limb 2. Monitoring vital signs every 4 hours 3. Administering opioid analgesics intramuscularly 4. Monitoring the biopsy site for swelling, bleeding, or hematoma

Administering opioid analgesics intramuscularly Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours or as prescribed to reduce edema. The vital signs are monitored every 4 hours for 24 hours for signs of complications such as infection and bleeding. The client usually requires mild analgesics. More severe pain usually indicates that complications are arising.

The nurse is caring for a client with a serum phosphorus level of 5.0 mg/dL (1.61 mmol/L). What other laboratory value might the nurse expect to note in the medical record? 1. Calcium level of 8 mg/dL (2.0 mmol/L) 2. Calcium level of 11.2 mg/dL (2.8 mmol/L) 3. Potassium level of 2.9 mEq/L (2.9 mmol/L) 4. Potassium level of 5.6 mEq/L (5.6 mmol/L)

Calcium level of 8 mg/dL (2.0 mmol/L) Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. Therefore, if these laboratory values are altered, this suggests dysfunction of the parathyroid gland. When calcium levels are elevated (normal is 9 to 10.5 mg/dL [2.25 to 2.75 mmol/L]) and phosphorous levels are decreased (normal is 3.0 to 4.5 mg/dL [0.97 to 1.45 mmol/L]) this suggests hyperparathyroidism. If the phosphorus level is elevated, the nurse should expect the calcium level to be low. Therefore, option 1 is the correct answer.

The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? 1. The pain level of the client 2. Blood pressure and respiratory rate 3. Capillary refill, sensation, color, and pulse of the left foot 4. The range of motion of the left knee when a continuous passive motion machine is used

Capillary refill, sensation, color, and pulse of the left foot The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a neurovascular assessment. Monitoring the pain level may be a component of the assessment but is not specifically related to neurovascular status. Blood pressure and respiratory rate may also be components of the nursing assessment but are not specific to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular status.

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? 1. Elevate the casted leg. 2. Contact the health care provider. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg.

Check the neurovascular status of the toes on the casted leg. An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine if the health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment.

A 39-year-old female with chronic intermittent pain in the epigastric area 2 to 3 hours after eating is diagnosed with a duodenal ulcer. Which of the following behaviors may have contributed to the development of the ulcer?

Cigarette smoking Response Feedback: Acid production is stimulated by cigarette smoking. Caffeinated beverages do not contribute to ulcer formation.

The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse should provide the client with which best instruction? 1. Eat meals at approximately the same time each day. 2. Adjust mealtimes depending on blood glucose levels. 3. Vary mealtimes if insulin is not administered at the same time every day. 4. Avoid being concerned about the time of meals as long as snacks are taken on time.

Eat meals at approximately the same time each day. Mealtimes must be approximately the same each day to maintain a stable blood glucose level. The client should not be instructed that mealtimes can be varied depending on blood glucose levels, insulin administration, or consumption of snacks.

The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication? 1. Slow pulse; lethargy; warm, dry skin 2. Elevated pulse; lethargy; warm, dry skin 3. Elevated pulse; shakiness; cool, clammy skin 4. Slow pulse, confusion, increased urine output

Elevated pulse; shakiness; cool, clammy skin Signs and symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin. The remaining options do not specify the manifestations of hypoglycemia.

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate? 1. Encourage the client's expression of feelings. 2. Assess the client's understanding of the disease process. 3. Encourage family members to share their feelings about the disease process. 4. Encourage the client to recognize that the body changes need to be dealt with.

Encourage the client to recognize that the body changes need to be dealt with. Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. The remaining options are appropriate because they address the client and family feelings regarding the disorder.

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? 1. Flat with the knees raised 2. In high Fowler's position, with the foot of the bed flat 3. In semi Fowler's position, with the foot of the bed flat 4. In semi Fowler's position, with the knees slightly flexed

In semi Fowler's position, with the knees slightly flexed Clients with low back pain often are more comfortable when placed in Williams' position. The bed is placed in semi Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. The remaining positions will not minimize the pain and may make the pain worse.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

Inadequate fluid volume An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse should anticipate that which substance will be elevated? 1. Glucose 2. Ketones 3. Glucagon 4. Lactate dehydrogenase

Ketones Ketones are a byproduct of fat metabolism. When this process occurs to an extreme, the resulting condition is called ketoacidosis. The remaining options are not associated with the breakdown of fats.

A client is admitted with a serum glucose level of 650 mg/dL (37.14 mmol/L) and diabetic ketoacidosis (DKA) is suspected. Which additional laboratory result does the nurse identify as being supportive of DKA? 1. Ketones in urine 2. Lactic dehydrogenase (LDH) of 200 U/L 3. pH of 7.52 on arterial blood gas (ABG) analysis 4. Blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L

Ketones in urine Ketones are a byproduct of fat metabolism. When this process occurs to the extreme, it is termed ketoacidosis. Ketone bodies are a product of fat metabolism, and the presence of moderate to high urine ketones (hyperketonuria) indicates a severe lack of insulin, such as in DKA. Options 2, 3, and 4 are incorrect. BUN of 10 mg/dL (3.6 mmol/L) is a normal value, as normal is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Elevations in LDH (normal is 100 to 190 U/L) can be indicative of heart failure, hemolytic disorders, hepatitis dysfunction, myocardial infarction, pulmonary embolus, or skeletal muscle damage. In acidotic conditions the pH will be decreased (normal is 7.35 to 7.45).

A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? 1. Median 2. Peroneal 3. Trigeminal 4. Spinal accessory

Median Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of injury, overuse, or disease. The peroneal nerve is in the leg. Trigeminal neuropathy results in facial pain, also known as tic douloureux. The spinal accessory nerve is a motor nerve impacting shoulder function.

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? 1. Maintain a supine position. 2. Monitor neck circumference every 4 hours. 3. Maintain a pressure dressing on the operative site. 4. Encourage deep-breathing exercises and vigorous coughing exercises.

Monitor neck circumference every 4 hours. After thyroidectomy, neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client should be placed in an upright position to facilitate air exchange. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. The nurse should assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

A 31-year-old female presents with midabdominal pain. She is expected to have acute pancreatitis. Which of the will be part of the treatment plan? (Select all that apply.)

Narcotic analgesics Restriction of food intake Nasogastric suctioning Antibiotics IV fluids Narcotic medications may be needed to relieve pain. To decrease pancreatic secretions and "rest the gland," oral food and fluids may be withheld, and continuous gastric suction is instituted. Nasogastric suction may not be necessary with mild pancreatitis, but it helps to relieve pain and prevent paralytic ileus in individuals who are nauseated and vomiting. Parenteral fluids are essential to restore blood volume and prevent hypotension and shock. Antibiotics may control infection. The risk of mortality increases significantly with the development of infection or pulmonary, cardiac, and renal complications.

A patient presents to the physician with complaints of constipation. Which of the following could be the cause?

Neurogenic disorder of the large intestine Sedentary lifestyle Low residue diet Aging Use of antacids Constipation can be caused by neurogenic disorders of the large intestine in which neural pathways or neurotransmitters are altered and colon transit time delayed. A low-residue diet (the habitual consumption of highly refined foods) decreases the volume and number of stools and causes constipation. A sedentary lifestyle and lack of regular exercise are other common causes of constipation. Lack of access to toilet facilities and consistent suppression of the urge to empty the bowel are other causes. Excessive use of antacids containing calcium carbonate or aluminum hydroxide often results in constipation. Opiates, particularly codeine, tend to inhibit bowel motility. Conditions associated with constipation include congenital megacolon, hypothyroidism, pelvic hiatal hernia, multiple sclerosis, spinal cord trauma, cancer, cerebrovascular disease, and irritable bowel syndrome-constipation predominant. Aging may result in changes in neuromuscular function, causing constipation.

The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? 1. Document the findings. 2. Notify the health care provider. 3. Apply antibiotic ointment to the pin sites. 4. Clean the pin sites more frequently than prescribed.

Notify the health care provider. A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be reported to the health care provider. Options 1, 3, and 4 are inappropriate nursing actions for this client before cleaning a newly assessed potentially infected pin site; the site would be cultured before either cleaning it or putting medication on it.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

Numbness and tingling in the fingers The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which nursing action would best assist the client with these manifestations? 1. Obtain dark glasses for the client. 2. Lubricate the eyes with tap water every 2 to 4 hours. 3. Administer methimazole every 8 hours around the clock. 4. Instruct the client to avoid straining or heavy lifting because this effort can increase eye pressure.

Obtain dark glasses for the client. Because photophobia (light intolerance) accompanies this disorder, wearing dark glasses is helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client would be at risk for developing an eye infection because the solution is not sterile. Methimazole is a thyroid inhibitor, but medication therapy for Graves' disease does not help to alleviate the clinical manifestation of exophthalmos. There is no need to avoid straining or heavy lifting with exophthalmos.

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1. Contact the health care provider. 2. Massage the skin at the edges of the cast. 3. Petal the cast edges with appropriate material. 4. Place a small facecloth in the cast around the edges of the cast.

Petal the cast edges with appropriate material. If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. It is not necessary to contact the health care provider unless skin breakdown is noted. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.

Place a clock and calendar in the client's room. An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? 1. Concern about the level of postoperative pain 2. The availability of assistance for the client after discharge 3. Whether the client needs a PRN prescription for an antianxiety agent 4. Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection

Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection Clients who receive cadaver bone may worry about contracting human immunodeficiency virus or hepatitis or another infection from the cadaver bone. To ease their fear clients need reassurance and information about the donor screening that is done. The level of pain that will be experienced in the postoperative period and the availability of assistance for the client after discharge should be included as part of the basic preparation of the client for surgery. Administering antianxiety medication is used as a last measure if other reassuring measures are not effective.

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site. 2. Call the health care provider (HCP). 3. Rewrap the residual limb with an elastic compression bandage. 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.

Rewrap the residual limb with an elastic compression bandage. If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the HCP were called, the prescription likely would be to reapply the compression dressing anyway

The nurse is caring for a postoperative client who has had an adrenalectomy. What should the nurse check for during the client's focused assessment? 1. Peripheral edema 2. Bilateral exophthalmos 3. Signs and symptoms of hypovolemia 4. Signs and symptoms of hypocalcemia

Signs and symptoms of hypovolemia 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 the remaining options.

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage him or her to remain still.

Stay with the victim and encourage him or her to remain still. With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? 1. Try to exercise before mealtimes. 2. Administer insulin after exercising. 3. Take a blood glucose test before exercising. 4. Exercise is best performed during peak times of insulin.

Take a blood glucose test before exercising. A blood glucose test performed before exercising provides the client with information regarding the need to consume a snack before exercising. Exercising during the peak times of insulin or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

Test the drainage for glucose. After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? 1. How to petal the edges of the cast to prevent crumbling of these edges 2. The need to notify the nurse if the plaster cast becomes warm during the first 24 hours 3. The correct method of using a thin object when the client needs to scratch the area beneath the cast 4. The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale

The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale Numbness, swelling, and cool, pale skin are findings that indicate a state of neurovascular compromise. This can lead to significant problems and potential loss of the limb. Although teaching the client how to petal the edge of a cast is commonly done to keep the edges from crumbling, this is not the priority at this time. Chemical reaction occurs while a plaster cast dries, causing the cast to be warm. This effect can last from 24 to 48 hours, depending on how long it takes for the cast to dry. It is inappropriate to place any objects under the edge of the cast because such maneuvers can result in tissue injury and consequent infection.

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? 1. The residual limb is washed gently and dried every other day. 2. The socket of the prosthesis must be dried carefully before it is used. 3. A residual limb sock must be worn at all times and changed twice a week. 4. The socket of the prosthesis is washed with a harsh bactericidal agent daily.

The socket of the prosthesis must be dried carefully before it is used. A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used.

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? 1. To treat thyroid storm 2. To prevent cardiac irritability 3. To treat hypocalcemic tetany 4. To stimulate release of parathyroid hormone

To treat hypocalcemic tetany Hypocalcemia, resulting in tetany, can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes; muscle spasms; or twitching, the health care provider is notified immediately. Calcium gluconate should be readily available in the nursing unit.

A nurse is assigned to care for a client with type 1 diabetes mellitus. During the shift, the nurse should monitor for which manifestation as a sign of hypoglycemia? 1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps

Tremors Decreased blood glucose levels trigger autonomic nervous system signs and symptoms, such as nervousness, irritability, and tremors. Hot, dry skin accompanies hyperglycemia. Anorexia and muscle cramps are unrelated to hypoglycemia.

The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse should instruct the client that it is acceptable to include which item in the diet? 1. Fish 2. Cereals 3. Vegetables 4. Meat and poultry

Vegetables The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. Vegetables are allowed in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals.

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1. Hypotension 2. Weak pedal pulses 3. Redness at the pin sites 4. Drainage at the pin sites

Weak pedal pulses Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, redness and/or drainage at the pin sites are incorrect. Hypotension is not directly associated with the use of this type of traction.

The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? 1. Yogurt 2. Turkey 3. Shellfish 4. Spaghetti

Yogurt The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? 1. "You will use full weight bearing by discharge." 2. "You will use partial weight bearing by discharge." 3. "You will use toe-touch weight bearing by discharge." 4. "You will need to remain on bed rest even after discharge."

You will use full weight bearing by discharge." After total knee arthroplasty, there is an emphasis on physical therapy as part of the plan of care. By discharge, the client should be using full weight bearing after working with therapy. The other options are incorrect.

A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? Select all that apply. a. Blood test for prostate-specific antigen (PSA) b. Urinalysis c. Transrectal ultrasound d. Digital rectal examination (DRE) e. Prostate biopsy

a. Blood test for prostate-specific antigen (PSA) d. Digital rectal examination (DRE) Prostate cancer is typically detected by testing the blood for PSA or by a DRE. It is recommended that both PSA and DRE be offered to men annually, beginning at age 50 years. If the PSA is elevated, then further laboratory work or a transrectal ultrasound (TRUS) and biopsy may be recommended.

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: a. Menstrual history, because it is generally nonthreatening. b. Obstetric history, because it includes the most important information. c. Urinary system history, because problems may develop in this area as well. d. Sexual history, because discussing it first will build rapport.

a. Menstrual history, because it is generally nonthreatening.

The nurse has just completed an inspection of a nulliparous womans external genitalia. Which of these would be a description of a finding within normal limits? a. Redness of the labia majora b. Multiple nontender sebaceous cysts c. Discharge that is foul smelling and irritating d. Gaping and slightly shriveled labia majora

b. Multiple nontender sebaceous cysts No lesions should be noted, except for the occasional sebaceous cysts, which are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetric; redness indicates inflammation or lesions. Discharge that is foul smelling and irritating may indicate infection. In the nulliparous woman, the labia majora meet in the midline, are symmetric and plump.

A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe: a. Testes that are hard and painful to palpation. b. Atrophic scrotum and a bilateral absence of the testis. c. Absence of the testis in the scrotum, but the testis can be milked down. d. Testes that migrate into the abdomen when the child squats or sits cross-legged.

c. Absence of the testis in the scrotum, but the testis can be milked down. Migratory testes (physiologic cryptorchidism) are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes. The affected side has a normally developed scrotum and the testis can be milked down. The other responses are not correct.

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. Does your muscle tone seem tense or limp? b. After the seizure, do you spend a lot of time sleeping? c. Do you have any warning sign before your seizure starts? d. Do you experience any color change or incontinence during the seizure?

c. Do you have any warning sign before your seizure starts? Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from 0 to 4+

c. Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting __________ sign and __________ sign. a. Tanner; Hegar b. Hegar; Goodell c. Chadwick; Hegar d. Goodell; Chadwick

d. Goodell; Chadwick

The nurse knows that a common assessment finding in a boy younger than 2 years old is: a. Inflamed and tender spermatic cord. b. Presence of a hernia in the scrotum. c. Penis that looks large in relation to the scrotum. d. Presence of a hydrocele, or fluid in the scrotum.

d. Presence of a hydrocele, or fluid in the scrotum. A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the scrotum. The other options are not correct.

The nurse is examining the glans and knows which finding is normal for this area? a. The meatus may have a slight discharge when the glans is compressed. b. Hair is without pest inhabitants. c. The skin is wrinkled and without lesions. d. Smegma may be present under the foreskin of an uncircumcised male.

d. Smegma may be present under the foreskin of an uncircumcised male. The glans looks smooth and without lesions and does not have hair. The meatus should not have any discharge when the glans is compressed. Some cheesy smegma may have collected under the foreskin of an uncircumcised male.

A 15-year-old boy is seen in the clinic for complaints of dull pain and pulling in the scrotal area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with: a. Epididymitis. b. Spermatocele. c. Testicular torsion. d. Varicocele.

d. Varicocele. A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by incompetent valves within the vein. Symptoms include dull pain or a constant pulling or dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner will feel a soft, irregular mass posterior to and above the testis that collapses when the individual is supine and refills when the individual is upright. (See Table 24-6 for more information and for the descriptions of the other options.)

An infant is diagnosed with Chiari II malformation. Which information should the nurse include when teaching the parents about the pathophysiology of this medical condition?

"The brain tissue is displaced into the spinal canal."

Which complication does the nurse expect to find in a child if the metabolic pathway of dietary phenylalanine is blocked due to a disorder?

Decreased melanin

Which action should the nurse take if the palmar grasp reflex is present in a 4-month-old infant?

Document the finding as expected.

Which client needs immediate attention?

One with status epilepticus

A child had a febrile seizure. Which goal is the priority?

Prevent fever

A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the: a. Testes. b. Prostate. c. Epididymis. d. Vas deferens.

a. Testes. Sperm production occurs in the testes, not in the other structures listed.

A client with hypovolemia experiences activation of the renin-angiotensin system to maintain blood pressure. The registered nurse determines that the new nurse understands that what substance is secreted if which statement is made? 1. "Cortisol will be secreted." 2. "Aldosterone will be secreted." 3. "Additional glucagon will be produced." 4. "Adrenocorticotropic hormone production will increase."

"Aldosterone will be secreted." Aldosterone is the primary mineralocorticoid that is produced and secreted in response to lowered blood volume. Cortisol is a glucocorticoid. Glucagon is produced by the pancreas and functions to oppose the action of insulin in regulating blood glucose levels. Adrenocorticotropic hormone is produced by the pituitary gland and stimulates the adrenal cortex to produce glucocorticoids and mineralocorticoids.

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms."

"I need to stop my insulin." When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones during illness.

A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect? 1. Urge incontinence 2. Total incontinence 3. Stress incontinence 4. Reflex incontinence

1 (► Urge incontinence occurs when the client experiences involuntary loss of urine soon after experiencing urgency. ► Total incontinence occurs when loss of urine is unpredictable and continuous. ► Stress incontinence occurs when the client voids in increments of less than 50 mL under conditions of increased abdominal pressure. ► Reflex incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained.)

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1. Nocturia 2. Incontinence 3. Enlarged prostate 4. Nocturnal emissions 5. Decreased desire for sexual intercourse

1, 2, 3 (► Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in all male clients over 50 years of age. ► Nocturnal emissions are commonly associated with prepubescent males. ► Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse.)

A client is diagnosed with epididymitis. The nurse checks the health care provider's prescriptions and expects that which measures will be prescribed? Select all that apply. 1. Sitz bath 2. Antibiotics 3. Scrotal elevation 4. Use of a heating pad 5. Bed rest with bathroom privileges

1, 2, 3, 5 (► Common interventions used in the treatment of epididymitis include bed rest with bathroom privileges, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. ► A heating pad would not be used because direct application of heat would enhance blood flow to the area, thereby increasing the swelling.)

The nurse is performing assessment on a client with acute kidney injury (AKI) who is in the oliguric phase. Which should the nurse expect to note? Select all that apply. 1. Increased serum creatinine level 2. A low and fixed specific gravity 3. Increased blood urea nitrogen (BUN) level 4. A urine output of 600 to 800 mL in a 24-hour period 5. Urine osmolarity of approximately 300 mOsm/kg (300 mmol/kg)

1, 2, 3, 5 (► During the oliguric phase of acute kidney injury, serum creatinine levels increase by approximately 1 mg/dL (88 mcmol/L) per day, and the BUN level increases by approximately 20 mg/dL (7.1 mmol/L) per day. ► The specific gravity of the urine is low and fixed, and the urine osmolarity approaches that of the client's serum level, or about 300 mOsm/kg (300 mmol/kg). ► Urine output is less than 100 mL in a 24-hour period.)

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy

1, 3, 4 (► Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. ► Treatment options include hemodialysis or kidney transplant. ► Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. ► Peritoneal dialysis is not a treatment option due to the infected cysts. The condition does not respond to immunosuppression.)

A nursing instructor is teaching the class about Addison's disease. The instructor determines that the class understands the disease process if they indicate which are affected in this disease? Select all that apply. 1. Androgens 2. Bicarbonate 3. Electrolytes 4. Glucocorticoids 5. Mineralocorticoids

1. Androgens 4. Glucocorticoids 5. Mineralocorticoids In Addison's disease, all three classes of corticosteroids are affected: glucocorticoids, mineralocorticoids, and androgens. Electrolytes and bicarbonate are not directly affected by Addison's disease.

An infant has premature closure of two cranial sutures during the first 18 to 20 months of life. Which condition will the nurse observe documented in the chart?

Craniosynostosis

A client diagnosed with polycystic kidney disease (PKD) has been taught about the treatment plan for this disease. The nurse should determine that the client needs further teaching if the client states that which is included in the treatment plan? 1. Genetic counseling 2. Sodium restriction 3. Increased water intake 4. Antihypertensive medications

2 (► Individuals with polycystic kidney disease seem to waste rather than retain sodium. ► Unless the client has problems with uncontrolled hypertension, increased sodium and water intake is needed. ► Antihypertensive medications are prescribed to control hypertension. ► Genetic counseling is advisable because of the hereditary nature of the disease.)

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client's record, should the nurse identify as a *risk factor* for this disorder? 1. Hypoglycemia 2. Diabetes mellitus 3. Coronary artery disease 4. Orthostatic hypotension

2 (► Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and presence of an indwelling urinary catheter or frequent catheterization. ► The conditions noted in the remaining options are not associated risk factors.)

The nurse is admitting a client from the postanesthesia care unit who has had *percutaneous nephrolithotomy for calculi* in the renal pelvis. The nurse anticipates that the client's care will most likely involve monitoring which device? 1. Ureteral stent 2. Suprapubic tube 3. Nephrostomy tube 4. Jackson-Pratt drain

3 (► A nephrostomy tube is put in place after percutaneous nephrolithotomy for calculi in the renal pelvis. ► The client also may have a Foley catheter to drain urine produced by the other kidney. ► The nurse monitors the drainage from each of these tubes and strains the urine to detect elimination of the calculous fragments. ► Options 1, 2, and 4 are incorrect.)

A client with prostatitis following kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that education was effective if the client makes which statement? 1. "I will stop antibiotic therapy when pain subsides." 2. "I will exercise as much as possible to stimulate circulation." 3. "I should use warm tub baths and analgesics to increase comfort." 4. "I will keep fluid intake to a minimum to decrease the need to void."

3 (► Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. ► The nurse also teaches the client to rest, increase fluid intake, and use sitz baths or warm tub baths for comfort. ► Antimicrobial therapy is always continued until the prescription is finished.)

A client with urolithiasis (struvite stones) has a history of chronic urinary tract infections (UTI). What should the nurse plan to teach the client to avoid? 1. Antibiotics 2. Foods that make the urine more acidic 3. Wearing synthetic underwear and pantyhose 4. Fruits such as currants, blueberries, and cranberries

3 (► Urolithiasis (struvite stones) can result from chronic infections. They form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. ► Teaching should focus on preventing infections and ingesting foods to make the urine more acidic. ► Foods such as currants, blueberries, and cranberries are acidic. ► The client should wear cotton, not synthetic, underclothing to prevent the accumulation of moisture and to prevent irritation of the perineal area, which can lead to infection. ► Antibiotics are not associated with chronic urinary tract infections.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

Obesity is define as a body mass index (BMI) greater than _____.

30

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red, bloody urine 2. Pain rated as 2 on a 0-10 pain scale 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

4

The nurse has given instructions about Kegel exercises to a female client with a cystocele. The nurse determines that the client needs further instruction if she makes which statement? 1. "I should stop and start my stream of urine during a voiding." 2. "I should tighten my perineal muscles for up to 10 seconds several times a day." 3. "I should tighten my perineal muscles for up to 5 minutes 3 or 4 times a day." 4. "I should begin voiding and then stop the stream, holding residual urine for an hour."

4 (►Kegel muscles strengthen the perineal floor and are useful in the prevention and management of cystocele, rectocele, and enterocele. ► Several ways to perform Kegel exercises are acceptable. ► One method entails starting and stopping the flow of urine during a single voiding for about 5 seconds. ► Also, these exercises may be done by holding perineal muscles taut for up to 10 seconds several times a day or for 5 minutes 3 or 4 times a day. ► Residual urine should not be held in the bladder for long periods because this could promote urinary tract infection.)

A client with diabetes mellitus has a blood glucose level of 50 mg/dL (2.85 mmol/L) and reports feeling hungry and shaky. Which should the nurse provide the client? 1. 3 oz of 2% milk 2. 4 oz of apple juice 3. 2 oz of orange juice 4. A teaspoon of granulated sugar

4 oz of apple juice When a client is exhibiting symptoms of mild hypoglycemia, the nurse should provide the client with 15 g of a simple carbohydrate to quickly increase the blood glucose level. One half cup of apple juice is equivalent to 15 g of carbohydrates. The items in the remaining options do not provide a sufficient amount of carbohydrate.

A 40-year-old male develops an intestinal obstruction related to protrusion of the intestine through the inguinal ring. This condition is referred to as:

A hernia Response Feedback: A hernia is a protrusion of the intestine through a weakness in the abdominal muscles or through the inguinal ring.

In alcoholic cirrhosis, hepatocellular damage is caused by:

Acetaldehyde accumulation Response Feedback: Alcoholic cirrhosis is caused by the toxic effects of alcohol metabolism on the liver. Alcohol is transformed to acetaldehyde, and excessive amounts significantly alter hepatocyte function and activate hepatic stellate cells, a primary cell involved in liver fibrosis.

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1. Altered body image 2. Inability to care for self 3. Disruption in coping ability 4. Difficulty maintaining health

Altered body image Altered body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client also may have the other problems as listed in the remaining options, but altered body image is the client problem that correlates best with the client's statement.

A 30-year-old obese female underwent gastric resection in an attempt to lose weight. Which of the following complications could the surgery cause?

Anemia Response Feedback: One of the complications is anemia due to iron malabsorption, which may result from decreased acid secretion.

The most common cause of chronic vascular insufficiency among the elderly is: Answer

Atherosclerosis Response Feedback: The most common cause of chronic vascular insufficiency is atherosclerosis, especially in the elderly.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat

Bending or lifting Low back pain that radiates into 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.

The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder? 1. Serum pH of 9.0 2. Absent ketones in the urine 3. Serum bicarbonate of 22 mEq/L (22 mmol/L) 4. Blood glucose level of 500 mg/dL (28.5 mmol/L)

Blood glucose level of 500 mg/dL (28.5 mmol/L) In the client with DKA, the nurse should expect to note blood glucose levels between 350 and 1500 mg/dL (20 and 85.7 mmol/L), ketonuria, serum pH less than 7.35, and serum bicarbonate less than 15 mEq/L (15 mmol/L).

A 54-year-old male is diagnosed with peptic ulcer disease. This condition is most likely caused by:

Breaks in the mucosa and presence of corrosive secretions Response Feedback: Peptic ulcer disease is caused by breaks in the mucosa and the presence of corrosive substances.

A 40-year-old male who consumes a diet high in fat and low in fiber is at risk for:

CRC Response Feedback: CRC is associated with dietary intake, primarily lack of fiber and high fat content.

A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

Calcium After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek's and Trousseau's signs. The correct treatment is administration of calcium gluconate or calcium lactate. The remaining options are unrelated to the client's complaints.

The nurse cares for an infant diagnosed with a myelomeningocele. What other structural defect will the nurse expect?

Chiari II malformation

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg (10.3 kPa)

Clear mentation An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen saturation should be higher than 95%.

Which of the GI cancers has the highest rate of incidence and is responsible for the highest number of deaths?

Colorectal Response Feedback: Colorectal cancer (CRC) is the third most common cause of cancer and cancer death in the United States for both men and women.

A 55-year-old female has general symptoms of gallstones but is also jaundiced. IV cholangiography would most likely reveal that the gallstones are obstructing the:

Common bile duct Response Feedback: Jaundice is due to obstruction of the common bile duct.

The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? 1. Crossing legs at the ankle 2. Using an elevated toilet seat 3. Placing a pillow between the legs 4. Keeping the legs abducted from the midline

Crossing legs at the ankle Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times.

A 22-year-old male underwent brain surgery to remove a tumor. Following surgery, he experienced a peptic ulcer. His ulcer is referred to as a(n) _____ ulcer.

Cushing Response Feedback: A Cushing ulcer is a stress ulcer associated with severe head trauma or brain surgery that results from decreased mucosal blood flow and hypersecretion of acid caused by overstimulation of the vagal nerve.

The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? 1. Devascularization 2. Infection of the bone 3. Decreased bone mass 4. Decreased bone density

Devascularization Osteomyelitis is an infectious process affecting the bone, bone marrow, and surrounding soft tissue. A microorganism gains entry into the blood and grows, causing increased pressure on the bone, leading to ischemia and ultimately necrosis as a result of devascularization. Infection of the bone occurs but is not specifically related to necrosis of the bone. Decreased bone mass and decreased bone density are also not related to necrosis of the bone.

Acute pancreatitis often manifests with pain to which of the following regions?

Epigastric Response Feedback: Epigastric or midabdominal pain ranging from mild abdominal discomfort to severe, incapacitating pain is one of the manifestations of pancreatitis.

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1. Fever and tachycardia 2. Pallor and tachycardia 3. Agitation and bradycardia 4. Restlessness and bradycardia

Fever and tachycardia Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100°F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

A newborn is born with separations in the skull at the suture lines. Which term should the nurse use to describe these openings?

Fontanelles: The bones of the infant's skull are separated at the suture lines, forming two "soft spots" called fontanelles: one diamond-shaped anterior fontanelle and one triangular-shaped posterior fontanelle.

The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? 1. Draw up the correct dosage of NPH insulin into the syringe. 2. Draw up the correct dosage of regular insulin into the syringe. 3. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. 4. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. The initial step in preparing an injection of insulin that is a mixture of NPH and regular insulin is to inject air into the NPH insulin bottle equal to the amount of insulin prescribed. The client would then be instructed to inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin would then be withdrawn, followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer acting form.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

Intravenous infusion of normal saline The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.

A 10-month-old is brought to the pediatrician by the mother who states the baby has been experiencing colicky pain followed by vomiting, sweating, nausea, and irritability. Testing reveals a condition in which one part of the intestine telescopes into another. From which type of intestinal obstruction is he suffering?

Intussusception Response Feedback: Telescoping of one part of the intestine into another; this usually causes strangulation of the blood supply and is more common in infants 10 to 15 months of age than in adults.

Tissue damage in pancreatitis is caused by:

Leakage of pancreatic enzymes Response Feedback: Leaked enzymes become activated, initiating autodigestion, inflammation, oxidative stress, and acute pancreatitis.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement.

Maintain a patent airway. Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

A nurse is assisting a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) to develop a plan to prevent a recurrence. Which is most important to include in the plan of care? 1. Test urine for ketone levels. 2. Eat 6 small meals per day. 3. Monitor blood glucose levels frequently. 4. Receive appropriate follow-up health care.

Monitor blood glucose levels frequently. Client education after DKA should emphasize the need for home glucose monitoring 2 to 4 times per day. Instructing the client to notify the health care provider when illness occurs is also important. The presence of urine ketones indicates that DKA has occurred already. The client should eat well-balanced meals with snacks as prescribed.

The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 1. Pressure on the spinal cord 2. Pressure on the spinal nerve root 3. Muscle spasm in the area of the herniated disk 4. Excess cerebrospinal fluid production in the area

Muscle spasm in the area of the herniated disk Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Pressure on a spinal nerve root causes the symptoms of sciatica.

Which of the following characteristics is associated with an acute occlusion of mesenteric blood flow to the small intestine?

Often precipitated by an embolism Response Feedback: Occlusion of blood flow is often precipitated by embolism.

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? 1. Sprained left ankle 2. Decreased calcium intake 3. Open trauma to the left leg 4. Starting to smoke cigarettes

Open trauma to the left leg Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.

A 20-year-old male was recently diagnosed with lactose intolerance. He eats an ice cream cone and develops diarrhea. His diarrhea can be classified as _____ diarrhea.

Osmotic (Response Feedback: A nonabsorbable substance in the intestine leads to osmotic diarrhea.)

A client's laboratory results indicate the serum calcium is 12 mg/dL (3 mmol/L) and the serum phosphorous is 2.1 mg/dL (0.697 mmol/L). Based on these findings, the nurse suspects imbalance of which hormone? 1. Thyroid hormone 2. Parathyroid hormone 3. Follicle-stimulating hormone 4. Adrenocorticotropic hormone

Parathyroid hormone Parathyroid hormone is responsible for maintaining serum calcium and phosphorous levels within normal range. Knowledge of normal ranges for serum calcium (9 to 10.5 mg/dL [2.25 to 2.75 mmol/L]) and serum phosphorous (3.0 to 4.5 mg/dL [0.97 to 1.45 mmol/L]) is needed to determine that the client's calcium is elevated and phosphorus is decreased, consistent with hyperparathyroidism. Thyroid hormone is responsible for maintaining a normal metabolic rate in the body. Follicle-stimulating hormone and adrenocorticotropic hormone are produced by the anterior pituitary gland. They are responsible for growth and maturation of the ovarian follicle and stimulation of the adrenal glands, respectively.

The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? 1. Pulling up using the trapeze 2. Flexing and extending the feet 3. Doing quadriceps-setting and gluteal-setting exercises 4. Performing active range of motion to the right ankle and knee

Performing active range of motion to the right ankle and knee Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion.

A nurse is performing an assessment on a 6-month-old infant. Which reflex will the nurse assess for in this infant?

Plantar grasp: Plantar grasp will be present until 10 months. The tonic neck disappears in 5 months. The stepping reflex is no longer obtainable in 6 weeks. The Moro disappears in 3 months.

A health care provider has prescribed propylthiouracil for a client with hyperthyroidism. The nurse recalls that first-line treatment calls for methimazole for medication therapy. The nurse should question the client about her past medical history, specifically regarding which condition? 1. Pregnancy 2. Renal failure 3. Prolonged QT interval 4. Adverse reaction to levothyroxine

Pregnancy Methimazole and propylthiouracil are both used to treat hyperthyroidism. Methimazole is considered first-line treatment; however, this medication cannot be used for clients who are in their first trimester of pregnancy, have had a previous adverse reaction to methimazole, or need rapid reduction of symptoms. Renal failure, prolonged QT interval, and adverse reaction to levothyroxine are not related to contraindications for methimazole.

The nurse cares for a child, 5 years old, who has been diagnosed with a brain tumor. Which clinical manifestation would be consistent with this medical diagnosis?

Projectile vomiting without nausea

The nurse is monitoring a diabetic client with a blood glucose level of 400 mg/dL (22.2 mmol/L). Which clinical manifestation would indicate diabetic ketoacidosis (DKA)? 1. Bradycardia 2. Cool, clammy skin 3. Lower extremity edema 4. Rapid, deep respirations

Rapid, deep respirations DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4. This is because the body's compensatory response to the metabolic acidosis is to increase carbon dioxide (CO2) excretion by the lungs through deep, rapid breathing (Kussmaul respirations). Options 1, 2, and 3 are incorrect, as clients with DKA are dehydrated and thus have an increased heart rate and dry, scaly skin and do not have lower extremity edema.

A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

Slightly elevating the foot of the bed The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. The remaining options are incorrect.

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced? 1. Strain 2. Sprain 3. Fracture 4. Contusion

Sprain A sprain is an injury to a ligament caused by a wrenching or twisting motion. Signs and symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on a muscle. Manifestations include soreness and pain with muscle use. Typical signs and symptoms of fracture are variable but include pain, loss of function in the affected area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

Temperature In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits.

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? 1. The client refuses care. 2. The client allows the family to assist in the care. 3. The client assists in self-care as much as possible. 4. The client allows the nurse to complete the care on a daily basis.

The client assists in self-care as much as possible. A successful outcome for the problem of self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allowed others to do the care.

The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? 1. The client's fear related to the use of crutches 2. The client's feelings about the restricted mobility 3. The client's understanding of the need for increased mobility 4. The client's vital signs, muscle strength, and previous activity level

The client's vital signs, muscle strength, and previous activity level Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. Previous activity level will provide information related to the tolerance of activity. The remaining options also are components of the assessment, but physiological needs take precedence over psychosocial needs.

The nurse is preparing for a client's postoperative return to the unit after a parathyroidectomy procedure. The nurse should ensure that which piece of medical equipment is at the client's bedside? 1. Cardiac monitor 2. Tracheotomy set 3. Intermittent gastric suction device 4. Underwater seal chest drainage system

Tracheotomy set Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a paramount concern for the nurse managing the care of a postoperative client who has had a parathyroidectomy. An emergency tracheotomy set is routinely placed at the bedside of the client who has undergone this type of surgery, in anticipation of this complication. The items in the remaining options are not specifically needed with this surgical procedure.

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? 1. Administer an enema daily. 2. Use a fracture pan for bowel elimination. 3. Use a bedside commode for all elimination needs. 4. Use a regular bedpan to prevent spilling of contents in the bed.

Use a fracture pan for bowel elimination. A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.

A multidisciplinary health care team is developing a plan of care for a client with hyperparathyroidism. The nurse should include which priority intervention in the plan of care? 1. Describe the use of loperamide. 2. Restrict fluids to 1000 mL per day. 3. Walk down the hall for 15 minutes 3 times a day. 4. Describe the administration of aluminum hydroxide gel.

Walk down the hall for 15 minutes 3 times a day. Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted. Discussing the use of medications is not the priority with this client.

A woman wanting to get pregnant asks the nurse how to prevent spina bifida. Which response by the nurse is best?

"You should take a multivitamin containing folic acid every day."

The adult intestine processes approximately _____ liters of luminal content per day, of which 99% of the fluid is normally reabsorbed.

9

Which of the following type(s) of hepatitis has an incubation period of up to 180 days?

A D Both hepatitis A and D have incubation periods of up to 180 days.

The school nurse cares for a 6-year-old child who has recurrent, severe headaches that are worse in the morning. Which action by the nurse is most appropriate?

Advise the parent to have the child evaluated by the pediatrician today: If a young child complains of repeated and worsening headache, a thorough investigation should take place because headache is an uncommon complaint in young children and could indicate a brain tumor; headaches caused by increased intracranial pressure usually are worse in the morning

An infant has an anomaly in which the soft, bony components of the skull and part of the brain are missing. What term is used to describe this finding?

Anencephaly: Anencephaly is an anomaly in which the soft, bony components of the skull and part of the brain are missing.

The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's (HCP's) prescriptions, if noted on the record, would indicate the need for clarification? 1. Assess vital signs and neurological status. 2. Instruct the client to avoid blowing his nose. 3. Apply a loose dressing if any clear drainage is noted. 4. Instruct the client about the need for a MedicAlert bracelet.

Apply a loose dressing if any clear drainage is noted. The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted after this procedure, the HCP needs to be notified. Therefore, clarification is needed regarding application of a loose dressing. The remaining options indicate appropriate postoperative interventions.

After hypophysectomy, a client complains of being thirsty and having to urinate frequently. What is the initial nursing action? 1. Increase fluid intake. 2. Document the complaints. 3. Assess for urinary glucose. 4. Assess urine specific gravity.

Assess urine specific gravity After hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should assess the specific gravity of the urine and notify the health care provider (HCP) if the result is lower than 1.006. Although increasing fluid intake and documenting the complaints may be components of the plan of care, they are not initial actions. Additionally, the HCP will prescribe increased fluids. Assessing for urinary glucose is unrelated to the client's condition.

A 13-year-old female confides to her mother that she binge eats and induces vomiting to prevent weight gain. This disease is referred to as:

Bulimia nervosa Response Feedback: Binge eating and vomiting is characteristic of bulimia nervosa. Anorexia nervosa is starvation eating.

Complete obstruction of bile flow to the liver would be manifested by:

Clay-colored stools Response Feedback: Complete obstruction of bile flow leads to clay-colored stools.

A client visits the health care provider's office for a routine physical examination and reports a new onset of intolerance to cold. Since hypothyroidism is suspected, which additional information would be noted during the client's assessment? 1. Weight loss and tachycardia 2. Complaints of weakness and lethargy 3. Diaphoresis and increased hair growth 4. Increased heart rate and respiratory rate

Complaints of weakness and lethargy Weakness and lethargy are the most common complaints associated with hypothyroidism. Other common symptoms include intolerance to cold, weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

A child is diagnosed with dystonic cerebral palsy. Which clinical manifestations will the nurse typically find upon assessment?

Extreme difficulty in fine motor coordination

What are the key signs of hydrocephalus in a child? Select all that apply.

Increased intracranial pressure, with distention or bulging of the fontanelles, and separation of the sutures are key signs of hydrocephalus.

The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? 1. Limit caffeine intake. 2. Limit intake of vitamin D. 3. Limit participation in activities such as walking and swimming. 4. Limit protein in the diet because it contributes to the incidence of bone demineralization.

Limit caffeine intake. Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium.

A 40-year-old male presents with epigastric pain. Tests reveal acute pancreatitis. The most likely cause of his condition is:

Obstruction of the biliary tract by a gallstone Response Feedback: Biliary tract obstruction by gallstones is one of the known causes of pancreatitis.

Cholecystitis is inflammation of the gallbladder wall usually caused by:

Obstruction of the cystic duct by a gallstone Response Feedback: Cholecystitis can be acute or chronic, but both forms are almost always caused by a gallstone lodged in the cystic duct.

A 60-year-old male is diagnosed with cancer of the esophagus. Which of the following factors most likely contributed to his disease?

Reflux esophagitis Response Feedback: Reflux is a factor in the development of esophageal cancer.

The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1. Restricting fluids 2. Maintaining bed rest 3. Eating a low-purine diet 4. Taking nonsteroidal antiinflammatory drugs

Restricting fluids Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bed rest during an acute attack until the pain subsides. A diet low in purine normally is prescribed. Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid.

Which cranial deformity results in restricted lateral growth of an infant's head?

Scaphocephaly: Scaphocephaly is the premature closure of the sagittal suture resulting in restricted lateral growth of the head.

A 34-year-old male was diagnosed with a bacterial GI infection. Which of the following types of diarrhea would most likely occur with his condition?

Secretory (Response Feedback: Infections lead to secretory diarrhea.)

A serious complication of paraesophageal hiatal hernia is:

Strangulation Response Feedback: Strangulation of the hernia is a major complication.

The risk of hypovolemic shock is high with acute mesenteric arterial insufficiency because:

Ischemia alters mucosal membrane permeability, and fluid is shifted to the bowel wall and peritoneum. Response Feedback: Fluid shifts lead to hypovolemia.

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? 1. "Your hair will need to be shaved." 2. "You will receive spinal anesthesia." 3. "You will need to ambulate after surgery." 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery."

"Brushing your teeth needs to be avoided for at least 2 weeks after surgery." A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site.

A client with diabetes mellitus has been instructed in the dietary exchange system. The client asks the nurse if bacon is allowed in the diet. Which nursing response is most appropriate? 1. "Bacon is not allowed." 2. "Bacon is much too high in fat." 3. "Bacon may be eaten if you eliminate 1 meat item from your diet." 4. "One strip of bacon may be eaten if you eliminate 1 teaspoon of butter."

"One strip of bacon may be eaten if you eliminate 1 teaspoon of butter." Bacon is a component of the fat group in the exchange system. One teaspoon of butter is equal to 1 teaspoon of margarine, 1 teaspoon of any oil, 1 tablespoon of salad dressing, 1 strip of bacon, 5 large olives, or 10 whole peanuts.

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? 1. "Don't be concerned; this problem can be covered with clothing." 2. "Usually these physical changes slowly improve following treatment." 3. "This is permanent, but looks are deceiving and are not that important." 4. "Try not to worry about it; there are other things to be concerned about."

"Usually these physical changes slowly improve following treatment." The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. All other options are not therapeutic responses.

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? 1. "I think you are making the right decision to have the surgery." 2. "You have concerns about the surgical treatment for your condition?" 3. "You are very ill. Your health care provider has made the correct decision." 4. "There is no reason to worry. Your health care provider is a wonderful surgeon."

"You have concerns about the surgical treatment for your condition?" 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 that 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 a 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.

The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client? 1. "You can take either hydrocortisone or fludrocortisone for replacement." 2. "You need to take your fludrocortisone 3 times a day to prevent a crisis." 3. "You need to increase salt in your diet, particularly during stressful situations." 4. "You need to decrease your dosages of glucocorticoids and mineralocorticoids during stressful situations."

"You need to increase salt in your diet, particularly during stressful situations." Addison's disease is a result of adrenocortical insufficiency, and management is focused on treating the underlying cause. Hormone therapy is used for replacement. Hydrocortisone has both glucocorticoid and mineralocorticoid properties and needs to be taken 3 times daily, with two thirds of the daily dose taken on awakening. Fludrocortisone is taken once daily in the morning. Salt additives are necessary, particularly during times of stress, to compensate for excess heat or humidity as a result of the condition. There needs to be an increased dose of cortisol given for stressful situations such as surgery or hospitalization. Therefore, option 3 is the correct answer.

Which child is at highest risk for ischemic stroke?

A 3-year-old client with sickle cell disease

The nurse is preparing to care for a client after parathyroidectomy. The nurse should plan for which action for this client? 1. Maintain an endotracheal tube for 24 hours. 2. Administer a continuous mist of room air or oxygen. 3. Place the client in a flat position with the head and neck immobilized. 4. Use only a rectal thermometer for temperature measurement.

Administer a continuous mist of room air or oxygen Humidification of air or oxygen helps to liquefy mucous secretions and promotes easier breathing after parathyroidectomy. Pooling of thick mucous secretions in the trachea, bronchi, and lungs will cause respiratory obstruction. The client will not necessarily have an endotracheal tube in place. Tympanic temperatures can be taken. Semi Fowler's position is the position of choice to assist in lung expansion and prevent edema. Rectal temperatures only are not required.

A client who has had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse should perform which action? 1. Administer an analgesic. 2. Notify the health care provider. 3. Immobilize the knee temporarily. 4. Put the client's knee through full passive range of motion.

Administer an analgesic. Pain with knee extension is a common complaint of clients after knee arthroplasty; therefore, administering an analgesic would be the appropriate action. Immobilizing the knee will not help. The pain may be the result of a flexion contracture that developed preoperatively as the client tried to reduce the pain by keeping the knee partially flexed much of the time. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. Pain is expected postoperatively, so there is no need to notify the health care provider based on the symptom described. Full passive range of motion can be harmful to the knee replacement.

The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? 1. Muscle metabolism and growth 2. Bone resorption and regeneration 3. Nervous system impulse transmission 4. Joint integrity and synovial fluid production

Bone resorption and regeneration Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning.

A 39-year-old female presents with abdominal pain and jaundice. She is diagnosed with gallstones and undergoes cholecystectomy. An analysis of her gallstones would most likely reveal a high concentration of:

Cholesterol Response Feedback: The majority of gallstones are composed of cholesterol.

A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse should expect an excess of which substance? 1. Calcium 2. Cortisol 3. Epinephrine 4. Norepinephrine

Cortisol Cushing's syndrome is characterized by an excess of cortisol, a glucocorticoid. Glucocorticoids are produced by the adrenal cortex. Calcium would be decreased in this disorder. Epinephrine and norepinephrine are produced by the adrenal medulla.

The nurse is admitting a client diagnosed with pheochromocytoma. The client is complaining of a pounding headache and palpitations and the blood pressure is 170/90 mm Hg. The nurse is aware that which substance is responsible for these clinical manifestations? 1. Cortisol 2. Androgens 3. Aldosterone 4. Epinephrine

Epinephrine Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine, which are produced by the adrenal medulla. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamines also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. In addition, the other substances listed (cortisol, androgens, and aldosterone) are produced by the adrenal cortex.

What is the effect of a thoracic-level lesion in a child with myelodysplasia?

Flaccid paralysis of lower extremities

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? 1. Glucagon 2. Glyburide 3. Metformin 4. Regular insulin

Glucagon A blood glucose level lower than 50 mg/dL (2.85 mmol/L) is considered to be critically low. Glucagon is used to treat hypoglycemia because it increases blood glucose levels. Insulin would lower the client's blood glucose and would not be an appropriate treatment for hypoglycemia. Glyburide and metformin are oral hypoglycemic agents used to treat type 2 diabetes mellitus and would not be given to a client with hypoglycemia. In addition, an oral medication would not be administered to an unconscious client.

A client with diabetes mellitus is being tested to determine long-term diabetic control. Which result should the nurse expect to see if the client's long-term control is within acceptable limits? 1. Glycosylated hemoglobin of <6% 2. Presence of ketones in the urine 3. Presence of albumin in the urine 4. Fasting blood glucose level of 150 mg/dL (8.57 mmol/L)

Glycosylated hemoglobin of <6% This measurement of glycosylated hemoglobin (HgbA1C) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. A HgbA1C of <6% is acceptable. The fasting blood glucose level should be 110 mg/dL (6 mmol/L). The urine should be free of both ketones and albumin.

A 6-week-old infant has bulging anterior and posterior fontanelles. Which condition should the nurse monitor for in this infant?

Hydrocephalus

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? 1. Hypotension and fever 2. Mental status changes and hypertension 3. Subnormal temperature and hypotension 4. Complaints of weakness and hypertension

Hypotension and fever 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. The remaining options are incorrect.

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? 1. Decreased heart rate and increased restlessness 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Increased heart rate and increased oxygen saturation

Increased heart rate and adventitious breath sounds Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The remaining options are incorrect.

A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? 1. Iodine 2. Calcium 3. Phosphorus 4. Magnesium

Iodine

A nurse is assessing the status of a client who returned to the surgical nursing unit after a parathyroidectomy procedure. The nurse would place highest priority on which assessment finding? 1. Laryngeal stridor 2. Difficulty voiding 3. Mild incisional pain 4. Absence of bowel sounds

Laryngeal stridor During the early postoperative period, the nurse carefully observes the client for signs of bleeding, which may cause swelling and compression of adjacent tissues. Laryngeal stridor results from compression of the trachea and is a harsh, high-pitched sound heard on inspiration and expiration. Laryngeal stridor is an acute emergency, necessitating immediate attention to avoid complete obstruction of the airway. The other options describe usual postoperative problems that are not life threatening.

A nurse is reviewing the health care provider's prescriptions for a client diagnosed with hypothyroidism. Which medication prescription should the nurse question and verify? 1. Acetaminophen 2. Docusate sodium 3. Morphine sulfate 4. Levothyroxine sodium

Morphine sulfate Medications are administered very cautiously to the client with hypothyroidism because of altered metabolism and excretion and depressed metabolic rate and respiratory status. Morphine sulfate would further depress bodily functions. Hormone replacement with levothyroxine sodium, a thyroid hormone, is a component of therapy. Stool softeners, such as docusate sodium, are prescribed to prevent constipation. Acetaminophen can be taken.

A nurse working in the United States screens a newborn for an inherited metabolic disorder of the nervous system. The nurse is testing for which disorder?

Phenylketonuria

A client with a history of diabetes mellitus has a fingerstick blood glucose level of 460 mg/dL. The home care nurse anticipates that which additional finding would be present with further testing if the client is experiencing diabetic ketoacidosis (DKA)? 1. Hyponatremia 2. Rise in serum pH 3. Presence of ketone bodies 4. Elevated serum bicarbonate level

Presence of ketone bodies DKA is marked by the presence of excessive ketone bodies. As a result of the acidosis, the pH and serum bicarbonate level would decrease. Hyponatremia is not related to DKA.

A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? 1. Quad cane 2. Wheelchair 3. Lofstrand crutch 4. Aluminum crutch

Quad cane A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as the one described in the question.

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1. Fever and bradycardia 2. Fever and hypertension 3. Tachycardia and hypotension 4. Bradycardia and hypertension

Tachycardia and hypotension Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period? 1. Vital signs 2. Fluid balance 3. Anxiety level 4. Creatinine levels

Vital signs Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

A deep recess formed by the peritoneum between the rectum and the cervix is called: a. the Chadwick sign. b. cystocele. c. rectocele. d. rectouterine pouch.

d. rectouterine pouch. The rectouterine pouch (or cul-de-sac of Douglas) is the deep recess between the rectum and the cervix. The cervical mucosa during the second month of pregnancy is blue, which is termed the Chadwick sign. The cervix may also turn blue in any condition causing hypoxia or venous congestion. A cystocele is an abnormality of the pelvic musculature in which the bladder prolapses into the vagina. A rectocele is an abnormality of the pelvic musculature in which the rectum prolapses into the vagina.

A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? 1. "When I have pain, I will take ibuprofen." 2. "I should perform low-impact exercises regularly." 3. "Because I have no symptoms, my disease is not progressing." 4. "I must notify my health care provider if I experience any hearing loss."

"Because I have no symptoms, my disease is not progressing." Paget's disease is characterized by skeletal deformities caused by abnormal bone resorption followed by abnormal regeneration. It is a chronic disease, and most persons who are affected by it are asymptomatic. Even though there may be no symptoms, excessive bone loss may have occurred. Over-the-counter nonsteroidal antiinflammatory drugs may be used for pain, and low-impact exercises may reduce pain and increase mobility. Bones in the ear may be affected, and pressure from an enlarged temporal bone may cause hearing loss. If hearing loss occurs, the health care provider is notified.

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? 1. "I can take medication if I need to during the collection." 2. "When I start the collection, I will urinate and discard that specimen." 3. "I will pour the urine in the collection bottle each time I urinate and refrigerate the urine." 4. "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."

"I can take medication if I need to during the collection." Clients are reminded not to take medications for 2 to 3 days before a 24-hour urine collection for 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.

The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? 1. "I should avoid contact sports." 2. "I should check my ankles for swelling." 3. "I need to avoid foods high in potassium." 4. "I need to check my blood glucose regularly."

"I need to avoid foods high in potassium." Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients with this condition experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? 1. "Flushing indicates a complication." 2. "I should stay on liquids for a couple of days." 3. "I need to ambulate every couple of hours faithfully for a few days." 4. "I need to drink plenty of water for 1 to 2 days after the procedure."

"I need to drink plenty of water for 1 to 2 days after the procedure." No special restrictions are necessary after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The very small amount of radioactivity from the isotope presents no hazard to the client or staff. The remaining options are unrelated to postprocedure care.

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which client statement indicates an understanding of the nurse's instructions? 1. "I expect to experience some tingling of my toes, fingers, and lips after surgery." 2. "I will definitely have to continue taking antithyroid medications after this surgery." 3. "I need to place my hands behind my neck when I have to cough or change positions." 4. "I need to turn my head and neck front, back, and laterally every hour for the first 12 hours after surgery."

"I need to place my hands behind my neck when I have to cough or change positions." The client is taught that tension needs to be avoided on the suture line; otherwise hemorrhage may develop. One way of reducing incisional tension is to teach the client how to support the neck when coughing or being repositioned. Likewise, during the postoperative period the client should avoid any unnecessary movement of the neck. That is why sandbags and pillows frequently are used to support the head and neck. Any postoperative tingling in the fingers, toes, and lips probably is due to injury to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately. Removal of the thyroid does not mean that the client will be taking antithyroid medications postoperatively. Thyroid replacement medications are necessary.

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1. "I should limit my fluids to 1 liter per day." 2. "I should use my treadmill or go for walks daily." 3. "I should follow a moderate-calcium, high-fiber diet." 4. "My alendronate helps to keep calcium from coming out of my bones."

"I should limit my fluids to 1 liter per day." In hyperparathyroidism, clients experience excess parathyroid hormone (PTH) secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are high, there is excess bone resorption (calcium is pulled from the bones). In clients with elevated serum calcium levels, there is a risk of nephrolithiasis. One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly weight-bearing activity, minimizes bone resorption and helps to protect against pathological fracture. Walking, as an exercise, should be encouraged in the client with hyperparathyroidism. Clients should follow a moderate-calcium, high-fiber diet. Even though serum calcium is already high, clients should follow a moderate-calcium diet because a low-calcium diet will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is deposited into the serum.

The nurse has provided home care measures to the client with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction? 1. "I should always wear a MedicAlert bracelet." 2. "I should perform my exercise at peak insulin time." j 3. "I should always carry a quick-acting carbohydrate when I exercise." 4. "I should avoid exercising at times when a hypoglycemic reaction is likely to occur."

"I should perform my exercise at peak insulin time." The client should be instructed to avoid exercise at peak insulin time because this is when a hypoglycemic reaction is likely to occur. If exercises are performed at this time, the client should be instructed to eat an hour before the exercise and drink a carbohydrate liquid. The remaining options are correct statements regarding exercise, insulin, and diabetic control.

The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? 1. "I should sit in my recliner when I get home." 2. "I need to keep my legs apart while sitting or lying." 3. "I should try to obtain an elevated toilet seat for use at home." 4. "I should contact the health care provider if the incision becomes red or irritated or if I note any drainage."

"I should sit in my recliner when I get home." After total hip replacement, the client should be instructed to sit on a high, firm chair. The client should be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The health care provider should be notified if the client notes the development of any redness, irritation, or drainage at the incision site.

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

"I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? 1. "I should slide objects rather than lifting them." 2. "I should try not to remain in the same position for a long period of time." 3. "I should use large joints instead of small joints when performing activities." 4. "Pain or fatigue is expected, and I should try to continue with the activity if this occurs."

"Pain or fatigue is expected, and I should try to continue with the activity if this occurs." The client should be instructed to use pain or fatigue as an indicator and guide to increase, maintain, or decrease an activity level. If pain or fatigue is experienced, the client should rest. The client should learn to slide objects rather than lifting them and not remain in the same position for a long time. Whenever possible, the client should use large joints instead of small joints for activities and should use the joints in their most natural position.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "NPH is a basal insulin, so I should exercise in the evening."

"The best time for me to exercise is after breakfast." Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10- to 15-gram carbohydrate snack, and they should check their blood glucose level before exercising. Option 1 is incorrect because clients with diabetes should exercise, though they should check with their health care provider before starting a new exercise program. Option 3 in incorrect; clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 4 is incorrect; NPH insulin in an intermediate-acting insulin, not a basal insulin.

After client education about the importance of sunscreen use and active vitamin production via the skin, the nurse determines that the client understands the teaching when which statement is made? 1. "Vitamin B is activated in the outer layer of the skin by the sun." 2. "Vitamin E deficiency occurs from lack of exposure to sunlight." 3. "Vitamin K can be depleted if exposed to excess ultraviolet light." 4. "Vitamin D is activated in the epidermis from ultraviolet light, such as sunlight."

"Vitamin D is activated in the epidermis from ultraviolet light, such as sunlight." Vitamin D is activated in the epidermis by ultraviolet (UV) light, such as sunlight. Once activated, it is distributed by the blood to the gastrointestinal tract to promote uptake of dietary calcium. The vitamins in the remaining options are neither activated nor depleted by UV light, such as sunlight.

The family of a bedridden client with type 2 diabetes mellitus and chronic kidney disease calls the nurse to report symptoms of headache, polydipsia, and increased lethargy. Which most important question should the nurse ask the family to determine a possible problem? 1. "What is the client's urine output?" 2. "What is the client's capillary blood glucose level?" 3. "Has there been any change in the dietary intake?" 4. "Have you increased the amount of fluids provided?"

"What is the client's capillary blood glucose level?" Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is an acute complication of type 2 diabetes mellitus leading to hyperglycemia and dehydration. Headache, polydipsia, and increasing lethargy can be caused by the dehydration. The remaining options will not assist in determining a possible problem.

The nurse is caring for a client diagnosed with type 1 diabetes mellitus experiencing the Somogyi effect. Which blood glucose results and treatment would the nurse expect? 1. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to decrease amount of evening insulin. 2. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to increase amount of evening insulin. 3. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 240 mg/dL (13.3 mmol/L). Instruct to decrease amount of evening insulin. 4. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 240 mg/dL (13.3 mmol/L). Instruct to increase amount of evening insulin.

0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to decrease amount of evening insulin. With the Somogyi effect, hyperglycemia occurs in the morning as a result of hypoglycemia during the night from too much evening insulin. Treatment includes having a bedtime snack, decreasing the amount of evening insulin, or both. Thus, option 1 is the correct answer (hypoglycemia during the night and hyperglycemia in the morning, which is treated by decreasing the evening dose of insulin). Option 2 is incorrect because it instructs the client to increase the evening dose of insulin. Options 3 and 4 are incorrect because the nighttime blood glucose levels indicate hyperglycemia, which would indicate dawn phenomenon.

The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement indicates that teaching was effective? 1. "I should check the fistula every day by feeling it for a vibration." 2. "I am glad that the laboratory will be able to draw my blood from the fistula." 3. "I should wear a shirt with tight arms to provide some compression on the fistula." 4. "I should check my blood pressure in the arm where I have my fistula every week."

1 (► An AV fistula provides access to the client's bloodstream for the dialysis procedure. ► The client is instructed to monitor fistula patency daily by palpating for a thrill (vibration feeling). ► The client is instructed to avoid compressing the fistula with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. ► The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth.)

Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies? 1. Serum potassium, serum calcium 2. Urinalysis, hematocrit, hemoglobin 3. Culture and sensitivity testing, serum sodium 4. Urine specific gravity, intravenous pyelogram

1 (► Because of the potentially life-threatening outcomes associated with hyperkalemia and hypocalcemia, they are the most relevant to nursing management of the client with CKD. ► The diagnostic tests in the remaining options may be helpful in diagnosing CKD or in monitoring treatment but are not the most relevant. ► Additionally, decreased hematocrit and hemoglobin occur in CKD because of the decreased level of erythropoietin. However, a decrease in hematocrit and hemoglobin may be reflective of various health alterations.)

Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the health care provider (HCP)? 1. Cloudy yellow dialysate output 2. Client refusal to take the stool softener 3. Previous evening's dwell time of 8 hours 4. Peritoneal catheter site is not red, and the skin has grown around the cuff

1 (► CAPD is a form of peritoneal dialysis in which exchanges are completed 4 or 5 times daily. ► Peritonitis is a major complication of this type of dialysis. ► Peritonitis can be recognized by cloudy dialysate outflow, fever, abdominal guarding (board-like abdomen), abdominal pain, pain on inflow, malaise, nausea, and vomiting. ► The client has the right to refuse medications, but it also is important for the nurse to explain the importance of medications to the client. ► Typically the dwell time during the night is for the entire time that the client sleeps, which could be around 7 to 9 hours. ► The peritoneal site should have intact skin. The skin grows around the peritoneal catheter cuff, and this prevents tunnel (around catheter) infections.)

A client has chronic kidney disease (CKD) that does yet not require dialysis. Which client statement indicates the need for further teaching? 1. "I will reduce the sodium in my diet, and I can use salt substitutes to spice my food." 2. "The amount of fluid I can have every day depends on the amount of urine I put out." 3. "I will weigh myself on my bathroom scale every morning right after I have urinated." 4. "I should report a gain in weight, trouble with my breathing, or increased leg swelling."

1 (► CKD is a condition in which the kidneys have progressive problems in their ability to clear nitrogenous waste products and control fluid and electrolyte balance within the body. ► Conservative treatment of CKD slows progression of the disease and includes reducing the protein, sodium, potassium, and phosphorus in the diet and controlling the blood pressure. ► It is important to reduce the sodium in the diet. Salt substitutes usually are potassium-based and should not be used by a client with CKD because of the risk of hyperkalemia. ► The client should alter the fluid intake in relation to urine output. Obtaining a daily weight is an important measurement that indicates fluid volume. ► The client should also monitor for signs and symptoms of fluid overload, which could include an increase in weight, edema, and fluid collection in the lungs.)

The client with chronic kidney disease (CKD) has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. Which action should the nurse immediately take? 1. Change the dressing. 2. Reinforce the dressing. 3. Flush the peritoneal dialysis catheter. 4. Scrub the catheter with povidone-iodine.

1 (► Clients with peritoneal dialysis catheters are at high risk for infection. ► A wet dressing is a conduit for bacteria to reach the catheter insertion site. ► The nurse ensures that the dressing is kept dry at all times. ► Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. ► Flushing the catheter is not indicated. ► Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.)

A client with chronic kidney disease (CKD) has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis? 1. Vital signs and weight 2. Potassium level and weight 3. Vital signs and blood urea nitrogen level 4. Blood urea nitrogen and creatinine levels

1 (► Following dialysis the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. ► Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. ► Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.)

The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? 1. Pale pink urine 2. Dark pink urine 3. Tea-colored urine 4. Bright red blood with small clots in the urine

1 (► If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through the Foley tubing should be pale pink. ► Dark pink urine indicates that the rate of the irrigation solution should be increased. ► Tea-colored urine is not seen after TURP but may be noted in a client with other renal disorders such as renal failure. ► Bright red bleeding and clots could indicate a complication, and if this is noted, it should be reported to the health care provider.)

The nurse is assessing a client who has returned from the postanesthesia care unit after transurethral resection of the prostate (*TURP*). The nurse should assess for which *color* in the *urinary drainage* tubing that indicates proper irrigation and adequate functioning of the device? 1. Pale pink 2. Dark pink 3. Bright red 4. Red with clots

1 (► If the bladder irrigation solution is infusing at a sufficient rate, the urinary drainage will be pale pink. ► A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. ► Bright red bleeding and red urine with clots should be reported to the surgeon because either finding could indicate complications.)

The nurse provides discharge instructions to a client after prostatectomy. What is the priority discharge instruction for this client? 1. Avoid driving a car for at least 1 week. 2. Increase fluid intake to at least 2.5 L/day. 3. Avoid lifting any objects greater than 30 pounds (13.6 kg). 4. Contact the health care provider (HCP) if small clots are noticed in the urine.

2 (► A daily intake of 2.5 L of fluid should be maintained to limit clot formation and prevent infection. ► Driving a car and sitting for long periods are restricted for at least 3 weeks. ► The client should be instructed to avoid lifting objects heavier than 20 pounds (9 kg) for at least 6 weeks. ► Passing small pieces of tissue or blood clots in the urine for up to 2 weeks after surgery is expected and does not necessitate contacting the HCP.)

The nurse is working on a medical-surgical nursing unit and is caring for several clients with chronic kidney disease. The nurse interprets that which client is best suited for peritoneal dialysis as a treatment option? 1. A client with severe heart failure 2. A client with a history of ruptured diverticula 3. A client with a history of herniated lumbar disk 4. A client with a history of 3 previous abdominal surgeries

1 (► Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease. ► Severe cardiac disease can be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. ► For the same reason, peritoneal dialysis may be indicated for the client with diabetes mellitus. ► Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticula or malignancies; extensive abdominal surgeries; history of peritonitis; obesity; and a history of back problems, which could be aggravated by the fluid weight of the dialysate. ► Severe disease of the vascular system also may be a relative contraindication.)

The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem? 1. Anger 2. Projection 3. Depression 4. Withdrawal

1 (► Psychosocial reactions to CKD and hemodialysis are varied and may include anger. ► Other reactions include personality changes, emotional lability, withdrawal, and depression. ► The individual client's response may vary depending on the client's personality and support systems. ► The client in this question is exhibiting anger. ► The client's behavior is not indicative of projection. ► In addition, the client's statement does not reflect withdrawal or depression.

A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? 1. Bearing down as if having a bowel movement 2. Tightening the muscles as if trying to prevent urination 3. Contracting the abdominal, gluteal, and perineal muscles 4. Tightening the rectal sphincter while relaxing abdominal muscles

1 (► The Valsalva maneuver (bearing down) is avoided after prostatectomy because it increases the risk of bleeding in the postoperative period. ► An acceptable exercise is to tighten the abdominal, gluteal, and perineal muscles as if trying to prevent urination. ► Another acceptable exercise is to tighten the rectal sphincter while relaxing the abdominal muscles; this prevents the Valsalva maneuver from occurring)

The nurse is preparing to teach *ostomy care* to a client who has just had a *urinary diversion*; the client expresses concern about body appearance. Which client action indicates that the best initial positive adaptation is being made? 1. Agrees to look at the ostomy 2. Asks to defer ostomy care to the spouse 3. Asks to wait 1 more day before beginning to learn ostomy care 4. States that ostomy care is the nurse's job while the client is in the hospital

1 (► The best initial positive step in learning to care for an ostomy and to accept it as a part of the self is to be able to look at the ostomy. ► Once the client is able to look at the ostomy and touch it, the client can proceed more successfully to learn about ostomy care. ► The other options all indicate a deferral or refusal on the part of the client, which makes them less than optimal choices.)

A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem? 1. Constipation 2. Dehydration 3. Inability to tolerate activity 4. Impaired physical mobility

1 (► The client with CKD is almost certain to have a problem with constipation as a result of factors such as fluid restriction, fatigue that limits exercise, and dietary restrictions. ► In addition, phosphate-binding antacids such as aluminum hydroxide gel cause constipation as a side effect. ► The other problems listed are unrelated to the information in the question.)

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Increased number of white blood cells in the urine

1 (► The creatinine level is the most specific laboratory test to determine renal function. ► The creatinine level increases when at least 50% of renal function is lost. ► A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. ► Increased white blood cells in the urine are noted with urinary tract infection.)

The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status? 1. Blood pressure 2. Apical heart rate 3. Jugular vein distention 4. Level of consciousness

1 (► The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. ► For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. ► The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. ► Jugular vein distention and level of consciousness are unrelated items.)

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1 (► The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. ► The presence of a thrill and bruit indicate patency of the fistula. ► Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency. ► Although the presence of a radial pulse in the left wrist and capillary refill less than 3 seconds in the nail beds of the fingers on the left hand indicate adequate circulation to the hand, they do not assess fistula patency.)

A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP before performing the catheterization. 2. Use a small-sized catheter and an anesthetic gel as a lubricant. 3. Administer parenteral pain medication before inserting the catheter. 4. Clean the meatus with soap and water before opening the catheterization kit.

1 (► The presence of blood at the urinary meatus may indicate urethral trauma or disruption. ► The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. ► The other options include performing the catheterization procedure and therefore are incorrect.)

The nurse is monitoring the urine output of a client with low serum protein level and urinary output less than 30 mL in the last hour. Based on these data, the nurse understands that low urinary output is caused by which force within the kidneys? 1. Oncotic pressure 2. Osmotic pressure 3. Filtration pressure 4. Hydrostatic pressure

1 (► The pulling pressure within the capillaries that is exerted by the plasma proteins is referred to as the oncotic pressure. ► Osmotic pressure is the movement of water along a pressure gradient. ► Filtration pressure is the pressure that is exerted with ultrafiltration, in which the pressure within the capillaries is greater than the pressure outside them; this results in fluids being pushed across the membrane into Bowman's capsule. ► Hydrostatic pressure in the capillaries allows fluid to be filtered out of the blood in the glomerulus.)

A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all that apply. 1. Using sterile technique for needle insertion 2. Using standard precautions in the care of the client 3. Giving the client a mask to wear during connection to the machine 4. Wearing full protective clothing such as goggles, mask, gloves, and apron 5. Covering the connection site with a bath blanket to enhance extremity warmth

1, 2, 3, 4 (► Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. ► It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and apron. ► The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.)

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5°C (*101.2°F*). Which nursing action is most appropriate? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

2 (► A temperature of 101.2°F (38.5°C) is significantly elevated and may indicate infection. The nurse should notify the health care provider (HCP). ► Dialysis clients cannot have fluid intake encouraged. ► Vital signs and the shunt site should be monitored, but the HCP should be notified first.)

The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse should determine that the client understands the instructions if the client states that which should be reported to the health care provider (HCP)? Select all that apply. 1. Frequent urination 2. Burning on urination 3. A temperature of 100.6°F (38.1°C) 4. New-onset shortness of breath 5. A blood pressure of 105/68 mm Hg

1, 2, 3, 4 (► The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection, such as frequent urination, burning on urination, and elevated temperature so that treatment may begin promptly. ► Lowered blood pressure is not a complication of polycystic kidney disease, and it is an expected effect of antihypertensive therapy. The client would be concerned about increases in blood pressure because control of hypertension is essential. ► The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, are also a concern.)

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. 1. Explaining the procedure to the client 2. Clamping the tubing of the drainage bag 3. Aspirating a sample from the port on the drainage tubing 4. Obtaining the specimen from the urinary drainage bag 5. Wiping the port with an alcohol swab before inserting the syringe

1, 2, 3, 5 (► A urine specimen is not taken from the urinary drainage bag. ► Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. ► In addition, it may become contaminated with bacteria from opening the system. ► The remaining options are correct interventions for obtaining the specimen.)

The nurse is participating in a prostate screening clinic for men. Which complaints by a client are associated with prostatism? Select all that apply. 1. Inability to stop urinating 2. Postvoid dribbling of urine 3. Increased episodes of nocturia 4. Unusual force in urinary stream 5. Hesitancy on initiating the urinary stream

1, 2, 3, 5 (► Signs and symptoms of prostatism include reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating, a sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, and an increase in episodes of nocturia. ► These signs and symptoms are the result of pressure of the enlarging prostate on the client's urethra.)

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if any contain or retain potassium. 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1, 2, 4 (► The normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). A potassium level of 7.0 is elevated. ► The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. ► The nurse should notify the HCP and also review medications to determine if any contain potassium or are potassium retaining. The client does not need to be put on NPO status. ► Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly.)

The nurse is caring for a client just after ureterolithotomy and is monitoring the drainage from the ureteral catheter hourly. Suddenly, the catheter stops draining. The nurse assesses the client and determines that which could be the cause of the problem? Select all that apply. 1. Blood clots 2. Mucous shreds 3. Ureteral edema 4. Chemical sediment 5. Catheter displacement

1, 2, 4, 5 (► After ureterolithotomy, a ureteral catheter is put in place. Urine flows freely through it for the first 2 to 3 days. ► As ureteral edema diminishes, urine leaks around the ureteral catheter and drains directly into the bladder. ► At this point, drainage through the ureteral catheter diminishes. ► Immediately after surgery, absence of drainage usually is caused by blockage from blood clots, mucous shreds, chemical sediment, or catheter displacement.)

The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor daily weight. 2. Maintain sodium restrictions. 3. Maintain a diet low in protein. 4. Monitor intake and output (I&O). 5. Maintain bed rest when edema is severe.

1, 2, 4, 5 (► Controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. ► If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. ► Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. ► Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. ► Bed rest is prescribed to promote diuresis when edema is severe.)

The client diagnosed with benign prostatic hyperplasia (BPH) is scheduled for a transrectal ultrasound examination and a test to measure the level of prostate-specific antigen (PSA). The client says to the nurse, "I can't remember . . . can you tell me again why I need these tests to be done?" The nurse responds, knowing that these tests are done for which purpose? 1. Specifically to predict the course of BPH 2. Help to rule out the possibility of cancer 3. Pinpoint the likelihood of developing urinary obstruction 4. Give an indication of whether intermittent self-catheterization is needed

2 (► A transrectal ultrasound examination and PSA level determination help to rule out the possibility of prostate cancer. ► They do not specifically predict the course of BPH or the development of complications such as urinary obstruction. ► These tests have nothing to do with determining need for self-catheterization.)

The nurse is caring for a client who had a transsphenoidal hypophysectomy. Which statements should the nurse include in the discharge teaching instructions? Select all that apply. 1. "Include adequate fiber and fluids in your diet." 2. "Wear slip-on shoes rather than those that need to be tied." 3. "A postnasal drip may be expected for several weeks after surgery." 4. "Brushing your teeth will not be permitted for at least 2 weeks after surgery." 5. "Contact your health care provider immediately if you develop any headache, fever, or neck stiffness."

1. "Include adequate fiber and fluids in your diet." 2. "Wear slip-on shoes rather than those that need to be tied." 4. "Brushing your teeth will not be permitted for at least 2 weeks after surgery." 5. "Contact your health care provider immediately if you develop any headache, fever, or neck stiffness." Clients who have undergone a transsphenoidal hypophysectomy will have an incision just above the upper lip so that the pituitary gland can be accessed and removed through the sphenoid sinus. After the gland is removed, a muscle graft is taken, often from the thigh, to support the area and prevent leakage of cerebrospinal fluid (CSF). Clients should be taught to include adequate fluids and fiber in the diet to prevent straining during a bowel movement. Clients must also avoid bending from the waist to pick up objects or tie shoes because these activities will increase intracranial pressure. The client should also be taught to avoid brushing the teeth for 2 weeks to allow time for the incision to heal. Infection can occur after surgery, so clients should be taught to immediately report headache, fever, and nuchal (neck) rigidity because these may be indicative of meningitis. Postnasal drip can be an indication of CSF leak and should be reported immediately.

The nurse caring for a male client newly admitted to the hospital with a diagnosis of pneumonia suspects that the client is also at risk for metabolic syndrome if which characteristics have been identified in this client? Select all that apply. 1. Hemoglobin A1C of 6.5% 2. Waist circumference of 36 inches 3. Triglycerides 160 mg/dL (1.81 mmol/L) 4. Consistent systolic blood pressures <130 mm Hg 5. Serial fasting glucose levels of 120 mg/dL (6.85 mmol/L), 132 mg/dL (7.54 mmol/L), and 128 mg/dL (7.31 mmol/L

1. Hemoglobin A1C of 6.5% 3. Triglycerides 160 mg/dL (1.81 mmol/L) 5. Serial fasting glucose levels of 120 mg/dL (6.85 mmol/L), 132 mg/dL (7.54 mmol/L), and 128 mg/dL (7.31 mmol/L) Features of metabolic syndrome include abdominal obesity: waist circumference of 40 inches (100 cm) or more for men; hyperglycemia: fasting blood glucose level of 110 mg/dL (6 mmol/L) or more or on medication treatment for elevated glucose; abnormal hemoglobin A1C: >6.0%; hypertension: systolic blood pressure of 130 mm Hg or more or diastolic blood pressure of 85 mm Hg or more or on medication treatment for hypertension; hyperlipidemia: triglyceride level of 160 mg/dL or more or on medication treatment for elevated triglycerides, normal triglyderides is 40 to 160 mg/dL (0.45 to 1.81 mmol/L); high-density lipoprotein cholesterol less than 40 mg/dL for men: normal is >40 mg/dL (>1.55 mmol/L). The client's risk factors include elevated triglyceride level, elevated hemoglobin A1C, and elevated fasting blood glucose levels.

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. 1. Hypotension 2. Leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia

1. Hypotension 3. Hyperkalemia In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with Addisonian crisis.

A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. 1. Ice bags 2. Elevation 3. Heating pad 4. Compression bandage 5. Range-of-motion exercises

1. Ice bags 2. Elevation 3. Heating pad 4. Compression bandage Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated initially by remembering the acronym RICE, which stands for rest, ice, compression, and elevation. Heat and range-of-motion exercises are contraindicated because they would increase swelling.

A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. 1. Infection 2. Recent injury 3. Inflammation 4. Degenerative disease 5. Developmental retardation

1. Infection 2. Recent injury 3. Inflammation Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur. These symptoms are not specifically associated with developmental retardation.

A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse should expect to note which abnormal finding documented on the client's medical record? 1. Bradycardia 2. Hypertension 3. Decreased cardiac output 4. Decreased central venous pressure

2 (► AKI caused by glomerulonephritis is classified as an intrinsic or intrarenal cause of renal failure. ► It is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ► AKI from a prerenal cause is characterized by decreased blood pressure, tachycardia, decreased cardiac output, and decreased central venous pressure. ► Bradycardia is not part of the clinical picture for any form of kidney failure.)

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCl. 2. Administer intravenous furosemide. 3. Restrict fluids to 800 mL over 24 hours. 4. Elevate the head of the bed to high Fowler's. 5. Administer a vasopressin antagonist as prescribed.

1. Initiate an infusion of 3% NaCl. 3. Restrict fluids to 800 mL over 24 hours. 5. Administer a vasopressin antagonist as prescribed Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Monitor daily weight. 2. Monitor intake and output. 3. Assess extremities for edema. 4. Maintain a high-sodium diet. 5. Maintain a low-potassium diet.

1. Monitor daily weight. 2. Monitor intake and output. 3. Assess extremities for edema. The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water.

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor for changes in mentation. 2. Encourage an intake of low-protein foods. 3. Encourage an intake of low-sodium foods. 4. Encourage fluid intake of at least 3000 mL per day. 5. Monitor vital signs, skin turgor, and intake and output.

1. Monitor for changes in mentation. 4. Encourage fluid intake of at least 3000 mL per day. 5. Monitor vital signs, skin turgor, and intake and output. The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.

The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. 1. Pyrexia 2. Elevated potassium level 3. Elevated white blood cell count 4. Elevated erythrocyte sedimentation rate 5. Bone scan impression indicative of infection

1. Pyrexia 3. Elevated white blood cell count 4. Elevated erythrocyte sedimentation rate 5. Bone scan impression indicative of infection Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.

The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. 1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 4. The client reports that she consumes calcium and vitamin foods and supplements daily. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition.

1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. Risk factors associated with osteoporosis include a sedentary lifestyle, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. Another risk factor associated with osteoporosis includes a diet that is deficient in calcium. Options 1, 2, 3, and 5 are risk factors associated with osteoporosis.

The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. 1. Thin body build 2. Smoking history 3. Postmenopausal age 4. Chronic corticosteroid use 5. High intake of dairy products 6. Family history of osteoporosis

1. Thin body build 2. Smoking history 3. Postmenopausal age 4. Chronic corticosteroid use 6. Family history of osteoporosis A high intake of dairy products is not associated with osteoporosis because dairy products are high in calcium. Other than low calcium intake, other risk factors for osteoporosis include a thin body frame, sedentary lifestyle, cigarette smoking, excessive alcohol intake, chronic illness, long-term use of corticosteroids, postmenopausal age, and a family history of osteoporosis.

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk

1. Twisting of the spine 3. Hyperflexion of the spine 6. Herniation of an intervertebral disk Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.

The nurse teaches a class on foot care for clients diagnosed with diabetes mellitus. Which instructions should the nurse include in the class? Select all that apply. 1. Wear closed-toe shoes. 2. Soak feet in hot water twice a day. 3. Massage lanolin lotion between the toes. 4. Cut toenails straight across and file the edges. 5. Pat feet dry gently, especially between the toes.

1. Wear closed-toe shoes. 4. Cut toenails straight across and file the edges. 5. Pat feet dry gently, especially between the toes. People with diabetes mellitus are at high risk for foot ulcerations and resultant lower extremity amputations. The development of diabetic foot complications can be the result of a combination of microvascular and macrovascular diseases that place the client at risk for injury and serious infection. Options 1, 4, and 5 are correct, as measures should be taken to teach clients how to prevent foot ulcers and injury. These measures include wearing closed-toe shoes to protect the feet and toes (especially for those with peripheral neuropathy), cutting toenails straight across and filing the edges to avoid sharp toenail edges and cutting the skin of the toe, and drying the feet gently and thoroughly (including between the toes) to prevent maceration of the skin and infections. Option 2 is incorrect, as clients with diabetes should avoid hot water due to neuropathy and possible burns. Option 3 is incorrect, as lotion between the toes is not advised; it is necessary to keep the area between the toes dry to avoid maceration and infections.

A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse should include which instruction in the plan? 1. Dietary restrictions 2. Technique of catheterization 3. External pouch and application care 4. Proper administration of prophylactic antibiotics

2 (► A Kock pouch is a continent internal ileal reservoir. ► The nurse instructs the client about the technique of catheterization. ► Dietary restrictions are not required. ► There is no external pouch. ► Antibiotics are not required unless an infection is present; also, antibiotics are prescribed by the health care provider.)

A *female* client who has been receiving *radiation* therapy for *bladder cancer* tells the nurse that it feels as if she is *voiding through the vagina*. The nurse interprets that the client may be experiencing which problem? 1. Rupture of the bladder 2. The development of a vesicovaginal fistula 3. Extreme stress because of the diagnosis of cancer 4. Altered perineal sensation as a side effect of radiation therapy

2 (► A complication of radiation therapy for bladder cancer is fistula formation. ► In women, this frequently is manifested as a vesicovaginal fistula, which is an opening between the bladder and the vagina. ► With this complication the client senses that urine is flowing out of the vagina. ► In men, a colovesical fistula may develop, which is an opening between the bladder and the colon. This is manifested as voiding urine that contains fecal material. ► The remaining options are incorrect interpretations.

A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? 1. Bradycardia 2. Hypertension 3. Decreased cardiac output 4. Decreased central venous pressure

2 (► AKI caused by glomerulonephritis is classified as intrinsic or intrarenal failure. ► This form of AKI commonly manifests with hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ► AKI from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. ► Bradycardia is not part of the clinical picture for any form of renal failure.)

The nurse is instructing a client with *diabetes mellitus* about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

2 (► An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. ► Diabetic clients may require extra insulin when receiving peritoneal dialysis. ► Peritonitis is a risk associated with breaks in aseptic technique. ► Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. ► Disequilibrium syndrome is a complication associated with hemodialysis.)

The nurse is providing instructions to a client who is scheduled for cystoscopy and possible biopsy under general anesthesia. Which information should the nurse include? 1. The procedure will take about 4 hours. 2. Intravenous fluids may be started on the day of the procedure. 3. Preprocedure sedatives are never administered with general anesthesia. 4. Only a full liquid breakfast may be allowed on the day of the procedure.

2 (► Client preparation for cystoscopy and possible biopsy includes informing the client that intravenous fluids will be started the day of the procedure to ensure adequate hydration and flow of urine. ► The procedure will take approximately 30 minutes to 1 hour. ► An informed consent is obtained from the client, and preprocedure sedatives are administered as prescribed. ► If a general anesthetic is to be used, the client is told that fasting is necessary after midnight before the procedure.)

The nurse is caring for a client with acute kidney injury (AKI) experiencing metabolic acidosis. When performing an assessment, the nurse should expect to note which breathing pattern? 1. Apnea 2. Kussmaul respirations 3. Decreased respirations 4. Cheyne-Stokes respirations

2 (► Clinical manifestations associated with AKI occur as a result of metabolic acidosis. ► The nurse would expect to note Kussmaul respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide. ► The breathing patterns noted in options 1, 3, and 4 are not characteristic of AKI.)

The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which information should the nurse plan to include in the teaching session? 1. Alter the perineal pH by using a spermicide with a condom. 2. Keep follow-up appointments for repeat cultures in 4 to 7 days. 3. Discontinue antibiotics after 3 weeks of uninterrupted administration. 4. Identify sexual partners for the past 12 months so they can be treated.

2 (► Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. ► Using a spermicide does not change the perineal pH. ► The infection can be prevented by the use of latex condoms. ► Chlamydial infection is treated with antibiotics, which are not discontinued until the prescribed course is completed. ► All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.)

The nurse provides instructions to a client about newly prescribed furosemide. Which information should the nurse use to provide instructions in this teaching session? 1. The medication acts on the distal tubule of the nephron. 2. The medication acts on the loop of Henle in the nephron. 3. The collecting duct of the nephron will be affected by this medication. 4. The site of action for furosemide is the proximal tubule of the nephron.

2 (► Furosemide works by acting to excrete sodium, potassium, and chloride in the ascending limb of the loop of Henle; therefore, options 1, 3, and 4 are incorrect.)

The nursing student is caring for a client with benign prostatic hyperplasia (BPH). The nursing instructor asks the student to identify the clinical manifestations associated with this condition. The student needs further teaching if the student states that which finding is an early symptom of BPH? 1. Nocturia 2. Hematuria 3. Decreased force of urine stream 4. Difficulty initiating urine stream

2 (► Hematuria is not an early sign of BPH. ► Nocturia, decreased force of urine stream, and difficulty initiating urine stream are all early signs of BPH.)

The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? 1. Prerenal 2. Intrinsic 3. Atypical 4. Postrenal

2 (► In intrinsic failure, there is a fixed specific gravity and the urine tests positive for proteinuria. ► In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. ► In postrenal failure, there is a fixed specific gravity and little or no proteinuria. ► There is no disorder known as atypical renal failure.)

The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? 1. Prevent fluid overload. 2. Prevent loss of electrolytes. 3. Promote the excretion of wastes. 4. Reduce the urine specific gravity.

2 (► In the diuretic phase, fluids and electrolytes are lost in the urine. ► As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. ► Options 1, 3, and 4 are not the primary concerns in this phase of AKI.)

The nurse checks the *serum myoglobin* level for a client with a *crush injury* to the right lower leg because the client is at risk for developing which type of *acute kidney injury*? 1. Prerenal 2. Intrarenal 3. Postrenal 4. Extrarenal

2 (► Serum myoglobin levels increase in crush injuries when large amounts of myoglobin and hemoglobin are released from damaged muscle and blood cells. ► The accumulation may cause acute tubular necrosis, an intrarenal cause of renal failure. ► Prerenal causes are conditions that interfere with the perfusion of blood to the kidney. ► Postrenal causes include conditions that cause urinary obstruction distal to the kidney. ► The cause and the type of renal failure may determine the interventions used in treatment.)

The nurse caring for a client immediately after transurethral resection of the prostate (*TURP*) notices that the client has suddenly become *confused and disoriented*. Which is the priority nursing action for this client? 1. Reorient the client. 2. Notify the health care provider (HCP). 3. Ensure that a clock and calendar are in the room. 4. Increase the flow rate of the intravenous infusion.

2 (► The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. ► This may occur because the flushing solution used during the operative procedure is hypotonic. ► If the solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. ► The nurse should notify the HCP of these symptoms. ► Reorienting the client and ensuring that a clock and calendar are visible may be helpful but do not correct the problem. ► The nurse does not increase the flow rate of an intravenous infusion without a prescription from the HCP. ► In addition, speeding up the flow rate could potentially worsen the problem, depending on the solution that is infusing.)

The nurse has performed a nutritional assessment on a client with cystitis. The nurse should tell the client to consume which beverage to minimize recurrence of cystitis? 1. Tea 2. Water 3. Coffee 4. White wine

2 (► Water helps flush bacteria out of the bladder, and an intake of 6 to 8 glasses per day is encouraged. ► Caffeine and alcohol can irritate the bladder. Therefore, alcohol- and caffeine-containing beverages such as coffee, tea, and wine are avoided to minimize risk.)

The nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room in the emergency department. The nurse should take which actions? Select all that apply. 1. Obtain an anesthesia consent. 2. Administer a prescribed analgesic. 3. Explain the procedure to the client. 4. Obtain informed consent for the procedure. 5. Inform the anesthesiologist of the time of the procedure.

2. Administer a prescribed analgesic. 3. Explain the procedure to the client; 4. Obtain informed consent for the procedure. Before a fracture is reduced, the client is informed about the procedure, and an informed consent is obtained. An analgesic is given as prescribed because the procedure is painful. Closed reductions may be done in the emergency department without anesthesia. Therefore, an anesthesia consent and anesthesiologist are not needed. If anesthesia is used, the procedure is done in the operating room, not in the emergency department.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level

2. Comatose state 3. Deep, rapid breathing 5. Elevated blood glucose level Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. 1. Anxiety 2. Leukocytosis 3. Chvostek's sign 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad

2. Leukocytosis 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to many disorders. Chvostek's sign is a test of nerve hyperexcitability associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve. Chvostek's sign has no association with complications of sublingual transsphenoidal hypophysectomy.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.

The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. 1. Lying prone 2. Sitting using a lumbar roll or pillow 3. Standing with one foot on a step or stool 4. Lying on the side, with knees and hips straight 5. Lift objects that need to be carried above elbow level. 6. Lean forward to reach objects, keeping the legs and knees straight.

2. Sitting using a lumbar roll or pillow 3. Standing with one foot on a step or stool The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level.

The nurse is urging a client to *cough and deep breathe* after *nephrectomy*. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of which factor? 1. A stress response to the ordeal of surgery 2. A latent fear of needing dialysis if the surgery is unsuccessful 3. Pain that is intensified because of the location of the incision near the diaphragm 4. Effects of circulating metabolites that have not been excreted by the remaining kidney

3 (► After nephrectomy, the client may be in considerable pain. This is because of the size of the incision and its location near the diaphragm, which make coughing and deep breathing very uncomfortable. ► For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. ► The items in the other options are not likely factors for the client's statement.)

A client is scheduled for surgical creation of an internal arteriovenous *(AV) fistula* on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? 1. The client has an accurate understanding of the procedure and aftercare. 2. The client does not realize how painful removal of the dialysis catheter will be. 3. The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. 4. The client is not aware that the alternative access site is left in place prophylactically for 2 months.

3 (► An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. ► Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period. ► Options 1, 2, and 4 are incorrect interpretations of the client's statement.

A client is being *evaluated* as a *potential kidney donor* for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. What is the most appropriate response by the nurse? 1. Helps reduce the cost of the preoperative workup 2. Saves the client and the recipient valuable preoperative time 3. Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor 4. Provides for a sufficient number of persons reviewing the case so that no information is overlooked

3 (► Both the kidney donor and the kidney recipient need thorough medical and psychological evaluation before transplant surgery. ► Separate teams evaluate the donor and the recipient to avoid a conflict of interest in providing care for the 2 clients. ► Options 1, 2, and 4 are not related to the purpose of this approach.)

In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate? 1. Glycosuria 2. Polyphagia 3. Crackles auscultated in the lungs 4. Blood pressure of 98/58 mm Hg

3 (► CKD is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. ► Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from the kidneys' inability to excrete water. ► Signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in the lungs. ► The typical signs and symptoms of CKD include proteinuria or hematuria, not glycosuria. ► The nurse would observe anorexia and nausea in this client, not polyphagia.)

Which client is most at risk for developing a Candida urinary tract infection (UTI)? 1. An obese woman 2. A man with diabetes insipidus 3. A young woman on antibiotic therapy 4. A male paraplegic on intermittent catheterization

3 (► Candida infections, which are fungal infections, develop in persons who are on long-term antibiotic therapy because an alteration of normal flora occurs. ► These infections also are commonly seen in clients with blood dyscrasias, diabetes mellitus, cancer, or immunosuppression and in those with a drug addiction.)

The nurse is providing dietary instructions to a client with an oxalate kidney stone. The nurse should instruct the client to avoid which food? 1. Breads 2. Poultry 3. Chocolate 4. Prune juice

3 (► Clients with oxalate stones should avoid foods high in oxalate, such as tea, instant coffee, cola drinks, beer, rhubarb, beans, asparagus, spinach, cabbage, chocolate, citrus fruits, apples, grapes, cranberries, and peanuts and peanut butter. ► Large doses of vitamin C may help increase oxalate excretion in the urine.)

A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect? 1. Infection 2. An intact catheter 3. Bowel perforation 4. Bladder perforation

3 (► Complications of a peritoneal catheter include infection, perforation of the bowel or bladder, and bleeding. ► Brown-tinged returns suggest bowel perforation, which usually is accompanied by severe abdominal pain and diarrhea. ► Cloudy or opaque returns suggest possible infection. ► Urine-colored returns suggest possible bladder perforation. ► An intact catheter is unrelated to the information provided in the question.

A client is being discharged to home while recovering from acute kidney injury (AKI). Reduced dietary intake of which substance indicates to the nurse that the client understands the dietary teaching? 1. Fats 2. Vitamins 3. Potassium 4. Carbohydrates

3 (► The excretion of potassium and maintenance of potassium balance are normal functions of the kidneys. ► In the client with AKI or chronic kidney disease, potassium intake must be restricted as much as possible (to 60 to 70 mEq/day). ► The primary mechanism of potassium removal during AKI is dialysis. ► Vitamins, carbohydrates, and fats are not normally restricted in the client with AKI unless a secondary health problem warrants the need to do so. ► The amount of fluid permitted is generally calculated to be equal to the urine volume plus the insensible loss volume of 500 mL.)

A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety? 1. There is a strong likelihood that the client will need dialysis within 5 to 10 years. 2. There is absolutely no chance of needing dialysis because of the nature of the surgery. 3. One kidney is adequate to meet the needs of the body as long as it has normal function. 4. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.

3 (► Fears about having only 1 functioning kidney are common in clients who must undergo nephrectomy for renal cancer. ► These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs, as long as it has normal function. Therefore, the remaining options are incorrect.)

The nurse is planning a teaching session with a client who has chronic kidney disease (*CKD*) about managing the condition between dialysis treatments. The nurse should plan to include the instruction that *weight gain between dialysis* treatments should be ideally what value? 1. 11 to 13 lbs (5 to 6 kg) 2. 4.5 to 9 lbs (2 to 4 kg) 3. 2 to 3 lbs (1 to 1.5 kg) 4. 1 to 2 lbs (0.5 to 1.0 kg)

3 (► Limiting weight gain to 2 to 3 lbs (1 to 1.5 kg) between dialysis treatments helps prevent the hypotension that occurs with the removal of large volumes of fluid during dialysis. ► The nurse instructs the client in how to manage daily fluid allotment to assist the client in staying within a low fluid intake range to prevent excess weight gain. ► Options 1, 2, and 4 are incorrect.)

A client passes a *urinary stone*, and laboratory analysis of the stone indicates that it is composed of *calcium oxalate*. On the basis of these data, which should the nurse specifically include in the dietary instructions? 1. Increase intake of dairy products. 2. Avoid citrus fruits and citrus juices. 3. Avoid green, leafy vegetables such as spinach. 4. Increase intake of meat, fish, plums, and cranberries.

3 (► Oxalate is found in dark green foods such as spinach. ► Other foods that raise urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. ► The food items in options 1, 2, and 4 are acceptable to consume.)

The nurse is teaching a client with nephrotic syndrome about managing the disorder. What should the nurse instruct the client to adjust according to the amount of edema present? 1. Salt intake 2. Water intake 3. Activity level 4. Use of diuretics

3 (► The client is taught to adjust the activity level according to the amount of edema. ► As edema decreases, activity can increase. Correspondingly, as edema increases, the client should increase rest periods and limit activity. ► Bed rest is recommended during periods of severe edema. ► The client with nephrotic syndrome usually has a standard limit set on sodium intake. ► Fluids are not restricted unless the client also is hyponatremic. ► Diuretics are prescribed on a specific schedule, and doses are not titrated according to the level of edema.)

The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily? 1. Pulse and respiratory rate 2. Amount of activity and sleep 3. Intake and output (I&O) and weight 4. Blood urea nitrogen (BUN) and creatinine levels

3 (► The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording I&O and measuring weight daily. ► Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day. ► It is not necessary to record the pulse and respiratory rate or the amount of activity and sleep; these parameters are not specifically related to hemodialysis. ► BUN and creatinine levels are not measured on a daily basis.)

A client who is to have a *cystectomy* with creation of an *ileal conduit* asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. Which response by the nurse is the most appropriate? 1. "All clients undergo bowel preparation with major surgery." 2. "This will decrease the chance of postoperative paralytic ileus." 3. "A portion of the bowel will be used to create the conduit for urinary diversion." 4. "This will reduce the chance that the surgeon will nick the bowel during surgery."

3 (► The client scheduled for surgical creation of either an ileal conduit or a reservoir undergoes bowel preparation the night before the procedure. ► Preparation can include intake of copious clear liquids, laxatives, enemas, and antibiotics, depending on health care provider preference. ► This is done primarily to prevent infection because a loop of bowel will be used to create the urinary diversion.)

A client is experiencing the syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in which parts of the nephron? 1. The glomerulus and the calices 2. The loop of Henle and the distal tubule 3. The distal tubule and the collecting duct 4. The proximal tubule and the loop of Henle

3 (► The distal tubule and the collecting duct of the nephron require the presence of ADH for water reabsorption. ► The hormone increases the permeability of the membranes to allow water to flow more easily along the concentration gradient. ► The glomerulus filters but does not reabsorb. ► The calices are responsible for collecting the urine. ► The proximal tubule and the loop of Henle reabsorb water without the assistance of ADH.)

The nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further teaching about the diuretic phase of acute kidney injury (AKI)? 1. "The increase in urine output indicates the return of some renal function." 2. "The diuretic phase develops about 14 days after the initial insult and lasts about 10 days." 3. "The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." 4. "The blood urea nitrogen and creatinine levels will continue to rise during the first few days of diuresis."

3 (► The diuretic phase of acute kidney injury is characterized by an increase in urine output of more than 1000 mL in a 24-hour period. ► This increase in urine output indicates the return of some renal function; however, blood urea nitrogen and creatinine levels continue to rise during the first few days of diuresis. ► The diuretic phase develops about 14 days after the initial insult and lasts about 10 days.)

A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse should observe for which most common manifestation of this disorder? 1. Headache 2. Hypotension 3. Flank pain and hematuria 4. Complaints of low pelvic pain

3 (► The most common findings with polycystic kidney disease are hematuria and flank or lumbar pain that is either colicky in nature or dull and aching. ► Other common findings include proteinuria, calculi, uremia, and palpable kidney masses. ► Hypertension is another common finding and may be associated with cardiomegaly and heart failure. ► The client may complain of a headache, but this is not a specific assessment finding in polycystic kidney disease.)

The nurse is caring for a client who was prescribed furosemide. The nurse should monitor the client for damage of which kidney structure? 1. Pelvis 2. Calyx 3. Nephron 4. Renal artery

3 (► The nephron is the functional unit of the kidney that is responsible for clearance of excess fluid and waste products of metabolism. ► The renal pelvis and calices collect urine to send to the ureter. ► The renal artery brings blood to the kidney for filtering by the nephron.)

The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The nurse reviews the health care provider's prescriptions and plans care, knowing that which client-related factor would increase the amount of blood flow to the kidneys? 1. Physiological stress 2. Release of norepinephrine 3. Release of low levels of dopamine 4. Sympathetic nervous system stimulation

3 (► The release of low levels of dopamine exerts a vasodilating effect on the renal arteries, increasing urinary output. ► The other options cause renal vasoconstriction.)

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, painful scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3 (► Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. ► Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. ► The remaining options do not present all of the accurate manifestations.)

The health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question? 1. Insert a saline lock. 2. Obtain a daily weight. 3. Provide a high-protein diet. 4. Administer a calcium supplement with each meal.

3 (► When a client experiences CKD, the blood urea nitrogen (BUN) and serum creatinine levels rise. The client also experiences increased potassium, increased phosphates, and decreased calcium. ► BUN and creatinine are the byproducts of protein metabolism, so monitoring protein intake is important, with care taken to include proteins of high biological value. ► Clients with CKD will have protein restricted early in the disease to preserve kidney function. In end-stage disease, protein is restricted according to the client's weight, the type of dialysis, and protein loss. ► With CKD, the nurse is concerned about fluid volume overload and accumulation of waste products. Because of the kidneys' inability to excrete fluid, it is important for the nurse to prevent as well as assess for early signs of fluid volume excess. ► Infusing an intravenous (IV) solution into a client with CKD significantly increases the risk for overload. If an IV access is needed, it usually involves only a saline lock. ► Obtaining the client's daily weight is one of the most important assessment tools for evaluating changes in fluid volume. ► The kidneys also are responsible for removing waste products. The client also receives phosphate binders, calcium supplements, and vitamin D to prevent bone demineralization (osteodystrophy) from chronically elevated phosphate levels.)

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. 1. Provide a warm environment for the client. 2. Instruct the client to consume a low-fat diet. 3. A thyroid-releasing inhibitor will be prescribed. 4. Encourage the client to consume a well-balanced diet. 5. Instruct the client that thyroid replacement therapy will be needed. 6. Instruct the client that episodes of chest pain are expected to occur.

3. A thyroid-releasing inhibitor will be prescribed. 4. Encourage the client to consume a well-balanced diet. The clinical manifestations of hyperthyroidism are the result of increased metabolism caused by high levels of thyroid hormone. Interventions are aimed at reduction of the hormones and measures to support the signs and symptoms related to an increased metabolism. The client often has heat intolerance and requires a cool environment. The nurse encourages the client to consume a well-balanced diet because clients with this condition experience increased appetite. Iodine preparations are used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Thyroid replacement is needed for hypothyroidism. The client would notify the health care provider if chest pain occurs because it could be an indication of an excessive medication dose.

A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. Antibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy

4 (► Acute rejection most often occurs within 1 week after transplantation but can occur any time posttransplantation. ► Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. ► Treatment consists of increasing immunosuppressive therapy. ► Antibiotics are used to treat infection. ► Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. ► Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery.)

A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? 1. Advancing uremia 2. Phosphate overdose 3. Folic acid deficiency 4. Aluminum intoxication

4 (► Aluminum hydroxide may be prescribed as a phosphate-binding agent. ► Aluminum intoxication can occur when there is an accumulation of aluminum, an ingredient in many phosphate-binding antacids. ► It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. ► It can be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. ► It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. ► The data in the question are not specifically associated with the other conditions noted in the options.)

The nurse has provided instructions regarding home care measures for a client with acute pyelonephritis. Which statement by the client indicates a need for further teaching? 1. "I should try to maintain an acid ash diet." 2. "I should increase my fluid intake to 3 L per day." 3. "I should take my daily dose of vitamin C to acidify the urine." 4. "I need to avoid alcohol and highly spiced foods but may continue to drink my coffee every day."

4 (► Clients with acute pyelonephritis should be instructed to try to maintain an acid ash diet, which may be of some benefit. ► Also, they should increase fluid intake to 3 L per day; this helps relieve dysuria and flushes bacteria out of the bladder. ► However, for clients with chronic pyelonephritis and renal dysfunction, an increase in fluid intake may be contraindicated. ► Medications such as vitamin C help acidify the urine. Juices such as cranberry, plum, and prune juice will leave an acid ash in the urine. ► Caffeine, alcohol, chocolate, and highly spiced foods are avoided to prevent potential bladder irritation.)

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4 (► Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. ► Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. ► At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. ► The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. ► Tachycardia and fever are associated with infection. ► Generalized weakness is associated with low blood pressure and anemia. ► Restlessness and irritability are not associated with disequilibrium syndrome.)

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the health care provider (HCP).

4 (► Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. ► These changes can cause cerebral edema that leads to increased intracranial pressure. ► The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. ► The HCP must be notified. ► Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the HCP.

The graduate nurse is caring for a client with decreased renal perfusion. The registered nurse determines that the graduate nurse demonstrates understanding of why this is occurring if which statement is made? 1. "It can be due to an increase in serotonin levels." 2. "It may be due to overhydration with intravenous fluids." 3. "It may be due to the client's hemoglobin of 13.2 g/dL (132 mmol/L)." 4. "It may be a consequence of decreased dopaminergic receptor stimulation."

4 (► Dopaminergic receptors are found in the renal blood vessels and in the nerves. When stimulated, they dilate renal arteries and help modulate release of the neurotransmitter dopamine. Renal artery dilation helps improve urine output by increasing blood flow through the kidneys. ► Serotonin is a local hormone that is released from platelets after an injury; it constricts arterioles but dilates capillaries. ► Dehydration, not overhydration, would decrease renal perfusion. ► A hemoglobin of 13.2 g/dL (132 mmol/L) is a normal value.)

The nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if, which 24-hour intake and output totals are noted? 1. Intake 1500 mL, output 800 mL 2. Intake 3000 mL, output 2000 mL 3. Intake 2400 mL, output 2900 mL 4. Intake 1800 mL, output 1750 mL

4 (► For the client on a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per day. ► The client's output in the same period should be about the same and does not include insensible losses, which are extra. ► Insensible losses are offset by the fluid in solid foods, which also is not measured.)

A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem? 1. The client washes hands at least once per day. 2. The client's temperature remains lower than 101°F (38.3°C). 3. The client avoids blood pressure (BP) measurement in the left arm. 4. The client's white blood cell (WBC) count remains within normal limits.

4 (► General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. ► The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. ► It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the problem of risk for injury.)

The spouse of a client with acute kidney injury (AKI) secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys? 1. The kidneys get fatigued from having to filter too much fluid. 2. The kidneys can react adversely to moderate doses of furosemide. 3. The kidneys will shut down easily if serum levels of digoxin are high. 4. The kidneys generally require and receive about 20% to 25% of the resting cardiac output.

4 (► Heart failure is referred to as a prerenal cause of acute kidney injury because heart failure results in decreased blood flow to the kidneys. ► The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. ► With a significant or prolonged decrease in blood supply, the kidneys can fail. ► Options 1 and 3 are incorrect. ► As for option 2, large doses of furosemide resulting in severe dehydration may lead to decreased kidney perfusion, but moderate doses of furosemide do not cause prerenal acute kidney injury, and furosemide may be used to treat acute kidney injury.)

A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test? 1. Bleeding time 2. Thrombin time 3. Prothrombin time (PT) 4. Partial thromboplastin time (PTT)

4 (► Heparin is the anticoagulant used most often during hemodialysis. ► The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. ► Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities. ► The PT is a test used to monitor the effect of warfarin therapy.)

The nurse is caring for a client immediately after *nephrectomy and renal transplantation*. What is the most appropriate *datum* to use in planning administration of intravenous fluids to this client? 1. A strict hourly rate of 100 mL 2. A strict hourly rate of 150 mL 3. One half of the previous hour's urine output 4. The number of milliliters in the previous hour's urine output

4 (► Intravenous fluids are managed very carefully after nephrectomy and renal transplantation. ► Fluids are usually given according to a formula that takes into account the previous hour's urine output. ► The desired urine output is generally high; therefore, options 1, 2, and 3 are incorrect.)

A client with nephrolithiasis arrives at the clinic for a follow-up visit. Laboratory analysis of the stone that the client passed 1 week earlier indicates that the stone is composed of calcium oxalate. Based on these data, what food item does the nurse instruct the client to avoid? 1. Pasta 2. Lentils 3. Lettuce 4. Spinach

4 (► Many kidney stones are composed of calcium oxalate. ► Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. ► Pasta, lentils, and lettuce are acceptable to consume.)

The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include? 1. "It is acceptable to eat whatever you want on the day before hemodialysis." 2. "It is acceptable to exceed the fluid restriction on the day before hemodialysis." 3. "Medications should be double-dosed on the morning of hemodialysis because of potential loss." 4. "Several types of medications should be withheld on the day of dialysis until after the procedure."

4 (► Many medications are dialyzable, which means that they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. ► It is not typical for medications to be double-dosed because there is no way to be certain how much of each medication is cleared by dialysis. ► Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.)

A client has just had a Foley catheter removed and is to be started on a *bladder retraining* program. Which intervention will provide the most useful information about the client's ability to empty the bladder? 1. Calculating total fluid intake for the shift 2. Recording the amount of the client's voidings 3. Assisting the client to the bathroom every 2 hours 4. Measuring postvoid residual using a bladder scan

4 (► Measuring postvoid residual gives specific information about the ability of the bladder to empty completely. ► Recording intake and output and assisting the client to the bathroom are general interventions but do not provide information about the client's ability to empty the bladder.)

The nurse is reviewing the assessment findings for a client with a diagnosis of nephrotic syndrome. Which should the nurse expect to note in this client? 1. Decreased serum lipids 2. Signs of fluid volume deficit 3. Decreased protein in the urine 4. Decreased serum albumin levels

4 (► Nephrotic syndrome describes a variety of signs and symptoms that accompany any condition that markedly impairs filtration by glomerular capillary membranes and results in increased permeability to protein. ► Hallmark signs and symptoms of this syndrome include increased serum lipids, edema, increased excretion of protein in the urine, and decreased serum albumin levels.

The nurse is teaching a client with renal cancer who is scheduled for a renal artery embolization about the procedure. Which statement by the client indicates that the educational session was effective? 1. "This will reduce the time needed for surgery by at least half because it provides hemostasis." 2. "This will cause the tumor to become tougher and easier to resect in surgery with the scalpel." 3. "This will prevent the risk of pulmonary embolism by occluding the renal artery and its branches." 4. "This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge.

4 (► Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. ► A secondary benefit is that it reduces the risk of hemorrhage during surgery. ► This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge, a balloon, a metal coil, or any of various other substances.)

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4 (► Steal syndrome results from vascular insufficiency after creation of a fistula. ► The client exhibits pallor and a diminished pulse distal to the fistula. ► The client also complains of pain distal to the fistula, caused by tissue ischemia. ► Warmth and redness probably would characterize a problem with infection. ► Ecchymosis and a bruit are normal findings for a fistula.

The ambulatory care nurse is providing instructions to a client after a cystoscopy. Which statement by the client indicates a need for further teaching? 1. "I should increase my fluid intake." 2. "I can apply heat to my lower abdomen." 3. "I may have some burning on urination for the next few days." 4. "If I notice any pink-tinged urine, I should contact the health care provider."

4 (► The client is instructed that pink-tinged urine and burning on urination are expected for 1 to 2 days after the procedure. ► Increased fluid intake is encouraged. ► Application of heat to the lower abdomen, administration of mild analgesics, and the use of sitz baths may relieve discomfort. ► The client also is advised to avoid alcoholic beverages for 2 days after the test.)

A client being discharged home after renal transplantation has a risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further teaching on measures to prevent and control infection if the client states that it is necessary to take which action? 1. Take an oral temperature daily. 2. Use good hand-washing technique. 3. Take all scheduled medications exactly as prescribed. 4. Monitor urine character and output at least 1 day each week.

4 (► The client receiving immunosuppressive medication therapy must learn and use infection control methods for use at home. ► The client self-monitors urine output and its characteristics on a daily basis. ► The client must learn proper hand-washing technique and should take the temperature daily to detect early infection. ► This is especially important because the client also takes corticosteroids, which mask signs and symptoms of infection. ► All medications should be taken exactly as prescribed.

A client is having difficulty coughing and deep-breathing because of pain after a nephrectomy. Which action by the nurse is helpful in promoting optimal respiratory function? 1. Administering pain medication just before ambulation 2. Administering pain medication when the client asks for it 3. Encouraging the use of the incentive spirometer every 8 hours 4. Assisting the client to splint the incision during respiratory exercise

4 (► The client who has had a nephrectomy may have pain with coughing and deep breathing and other respiratory exercises because the location of the incision is so close to the diaphragm. ► The nurse assists the client by offering opioid analgesics when due, encouraging incentive spirometer use hourly, and assisting the client to splint the incision during coughing. ► If the client takes pain medication only before ambulation, control of pain may be insufficient, which will not promote optimal respiratory function (pain medication should be offered 30 to 45 minutes before the client ambulates). ► Laparoscopic nephrectomy can also be performed. Compared to conventional nephrectomy, the laparoscopic approach is less painful and requires no sutures or staples, involves a shorter hospital stay, and has a much faster recovery.)

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Swollen, and boggy prostate gland 3. Tender and edematous prostate gland 4. Tender, indurated prostate gland that is warm to the touch

4 (► The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. ► Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.)

The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse should assess this client carefully for signs and symptoms of which problem? 1. Brain attack 2. Respiratory failure 3. Myocardial infarction 4. Acute tubular necrosis

4 (► The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. ► When a large amount of myoglobin is being cleared from the body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis. ► This is one form of acute kidney injury. ► The remaining options are unrelated to a positive myoglobin level.

The home health nurse is planning to make a home visit to a client who has undergone surgical creation of an *ileal conduit*. The nurse should include which information on ostomy care in discussion with the client? 1. Plan to do appliance changes in the late evening hours. 2. Cut an opening that is slightly smaller than the stoma in the face plate of the appliance. 3. Appliance odor from urine breakdown to ammonia can be minimized by limiting fluids. 4. Cleanse the skin around the stoma, using gentle soap and water, and then rinse and dry well.

4 (► The skin around the stoma is cleansed at each appliance change using a gentle, nonresidue soap and water. The skin is rinsed and then dried thoroughly. ► The appliance should be changed early in the morning because urine production is slowest from no fluid intake during sleep. ► The appliance is cut so that the opening is not more than 3 mm larger than the stoma. An opening smaller than the stoma will prevent application of the appliance. ► Generous fluid intake is encouraged to dilute the urine, decreasing the intensity of odor.)

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4 (► Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. ► Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. ► Hematuria is not associated with urethritis. ► Proteinuria is associated with kidney dysfunction.)

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hour 2. A coagulation time of 5 minutes 3. A heart rate that is 90 beats/minute and irregular 4. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)

A heart rate that is 90 beats/minute and irregular Pheochromocytoma is a catecholamine-producing tumor usually found in the adrenal medulla, but extraadrenal locations include the chest, bladder, abdomen, and brain; it is typically a benign tumor but can be malignant. Excessive amounts of epinephrine and norepinephrine are secreted. The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) is a normal finding.

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? 1. A normal response that indicates the presence of phantom limb pain 2. A normal response that indicates the presence of phantom limb sensation 3. An abnormal response that indicates that the client is in denial about the limb loss 4. An abnormal response that indicates that the client needs more psychological support

A normal response that indicates the presence of phantom limb sensation Phantom limb sensations are felt in the area of the amputated limb. These sensations can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area of the amputation. Whenever possible, the client should be prepared for these sensations. The client also may feel painful sensations in the amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client should be prepared for this, too, whenever possible.

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1. A trochanter roll to prevent abduction during turning 2. A pillow to keep the right leg abducted during turning 3. A pillow to keep the right leg adducted during turning 4. A trochanter roll to prevent external rotation during turning

A pillow to keep the right leg abducted during turning After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned.

A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? 1. A bath blanket and the assistance of four people 2. A bath blanket and the assistance of three people 3. A transfer (slider) board and the assistance of two people 4. A transfer (slider) board and the assistance of three people

A transfer (slider) board and the assistance of three people After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer (slider) board and the assistance of three people with one at the head to protect or support the client's head and neck. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously.

Administer short-duration insulin intravenously. Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.

The nurse is assessing a client who has a diagnosis of goiter. Which should the nurse expect to note during the assessment of the client? 1. An enlarged thyroid gland 2. The presence of heart damage 3. Client complaints of chronic fatigue 4. Client complaints of slow wound healing

An enlarged thyroid gland An enlarged thyroid gland develops in the client with goiter because of an excessive amount of thyroxine in the thyroid gland. Heart damage occurs with selenium deficiency. In addition, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests in addition to the assessment would be necessary to determine heart damage. Chronic fatigue occurs with iron deficiency. Slow wound healing occurs with zinc deficiency.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? 1. A decreased-calorie diet 2. An increased-calorie diet 3. A decreased amount of NPH insulin daily insulin 4. An increased amount of NPH insulin daily insulin

An increased amount of NPH insulin daily insulin Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection is present, an increase in the dose of insulin will be required to facilitate the transport of excess glucose into the cells. The client will not necessarily need an adjustment in the daily diet.

The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? 1. Fractured knee 2. Dislocated knee 3. Fracture of the femoral neck 4. Fracture of the midshaft of the femur

Fracture of the femoral neck Typical signs after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. The signs noted in the question are not associated with a fractured or dislocated knee or a fractured femur.

An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1. Anemia 2. Fractures 3. Infection 4. Muscle sprains

Fractures The client is most at risk for fractures as a result of osteoporosis. Although other complications can occur, fracture is the greatest concern. Anemia and infection can occur with bone marrow disorders, and muscle sprains are unrelated to osteoporosis.

A 16-year-old female presents with abdominal pain in the right lower quadrant. Physical examination reveals rebound tenderness and a low-grade fever. A possible diagnosis would be:

Appendicitis Response Feedback: Appendicitis is manifested by right lower quadrant pain with rebound tenderness.

A client received 5 units of insulin aspart subcutaneously just before eating lunch at 12:00 p.m. The nurse should assess the client for a hypoglycemic reaction at which times? 1. Between 1:00 and 3:00 p.m. 2. 10 minutes after administration 3. Between 4:00 p.m. and 12:00 a.m. 4. Between 8:00 and 10:00 p.m.

Between 1:00 and 3:00 p.m. Insulin aspart is a rapid-acting insulin. Its onset of action is 15 minutes; it peaks in 1 to 3 hours, and its duration of action is 3 to 5 hours. Hypoglycemic reactions are most likely to occur during peak time.

A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestations best support a diagnosis of DKA? 1. Blood glucose 500 mg/dL (27.8 mmol/L); arterial blood gases: pH 7.30, PaCo2 50, HCO3- 26. 2. Blood glucose 400 mg/dL (22.2 mmol/L); arterial blood gases: pH 7.38, PaCo2 40, HCO3- 22. 3. Blood glucose 450 mg/dL (25.0 mmol/L); arterial blood gases: pH 7.48, PaCo2 39, HCO3- 29. 4. Blood glucose 350 mg/dL (19.4 mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3- 14.

Blood glucose 350 mg/dL (19.4 mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3- 14. DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an elevated blood glucose and the arterial blood gases (ABGs) indicate metabolic acidosis. Option 1 is incorrect, as the ABGs indicate respiratory acidosis; option 2 is incorrect, as the ABG values are within normal; and option 3 is incorrect, as the ABGs indicate metabolic alkalosis.

A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? 1. Feeling isolated 2. Body image alteration 3. Inability to perform activities 4. Inability to engage in physical mobility

Body image alteration The client experiences an altered image of the body related to a change in the structure and function of the affected leg. No data in the question support a client's problem of feeling isolated or unable to perform activities or engage in physical mobility.

The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? 1. Tinnitus 2. Fatigue 3. Bone pain 4. Difficulty with ambulating

Bone pain Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in the skull. Fatigue or difficulty with ambulation may occur but would not be the most common symptom

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? 1. Intact skin surfaces 2. Bowel movement every 4 days 3. Active range of motion of uninvolved joints 4. Absence of redness and swelling in the affected extremity

Bowel movement every 4 days A bowel movement every 4 days is insufficient. The client should be having a bowel movement a minimum of every other day. Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (redness and swelling in the affected extremity), active range of motion to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.

A home health nurse is visiting a client with type 1 diabetes mellitus. The client tells the nurse that he is not feeling well and has had a "respiratory infection" for the past week, which seems to be getting worse. After interviewing the client, what should be the initial nursing action? 1. Document the assessment data. 2. Check the client's blood glucose. 3. Notify the health care provider (HCP). 4. Obtain the client's sputum for culture and sensitivity

Check the client's blood glucose. Uncontrolled hyperglycemia may lead to the production of ketones, thus leading to diabetic ketoacidosis (DKA), a life-threatening condition. The most common precipitating factor for development of DKA is infection. Assessment data should be documented but are not a priority. The HCP may need to be notified if the client's blood glucose is elevated and the client has other symptoms of DKA or a respiratory infection. After determining the client's blood glucose, the nurse should obtain a sputum sample if the client is expectorating yellow, green, or bloody secretions.

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? 1. Simple fracture 2. Greenstick fracture 3. Compound fracture 4. Comminuted fracture

Comminuted fracture A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.

The nurse caring for a client who underwent intracranial surgery is suspected of having diabetes insipidus. Which finding noted by the nurse is consistent with this complication of surgery? 1. Complaints of excessive thirst 2. Urine specific gravity of 1.030 3. Urine output of 10 to 15 mL/hour 4. Systolic blood pressures running consistently over 150 mm Hg

Complaints of excessive thirst Diabetes insipidus results from insufficient antidiuretic hormone (ADH) production, which in this case was caused by the intracranial surgery. Findings associated with diabetes insipidus include greatly increased urine output, low urine specific gravity (<1.005), hypotension, signs of dehydration, increased plasma osmolarity, increased thirst, and output that does not decrease when fluid intake decreases. A complaint of thirst is the only option consistent with diabetes insipidus.

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? 1. Crackers with cheese and tea 2. Graham crackers and warm milk 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar

Graham crackers and warm milk 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.

The nurse is providing instructions regarding home care measures to a client with diabetes mellitus and instructs the client about the causes of hypoglycemia. The nurse determines that additional instruction is needed if the client identifies which as a cause of hypoglycemia? 1. Omitted meals 2. Increased intensity of activity 3. Decreased daily insulin dosage 4. Inadequate amount of fluid intake

Decreased daily insulin dosage Decreasing the dose of insulin will lead to hyperglycemia. Causes for hypoglycemic reactions include delayed consumption of meals and lack of necessary amounts of food. Other causes include the administration of excessive insulin or oral hypoglycemic medications, vomiting associated with illness, and strenuous exercise, which may potentiate the action of insulin.

A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in a client with diabetes mellitus who has gastroenteritis. Which is the appropriate nursing intervention? 1. Offer water only until the client is able to tolerate solid foods. 2. Withhold all fluids until vomiting has ceased for at least 4 hours. 3. Encourage the client to take 8 to 12 oz of fluid every hour while awake. 4. Maintain a clear liquid diet for at least 5 days before advancing to solids.

Encourage the client to take 8 to 12 oz of fluid every hour while awake .Small amounts of fluid may be tolerated, even when vomiting is present. The nurse should encourage liquids containing glucose and electrolytes every hour. The remaining options will not provide the adequate intake needed by the client with diabetes mellitus.

A young man with type 1 diabetes mellitus tells the nurse that he might lose his job because he has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes and that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? 1. Ask the client if he indeed has been drinking at work. 2. Ask the client what he does to treat his hypoglycemia. 3. Contact the local employment office to help him find another job 4. Examine factors with the client that may be causing frequent hypoglycemic episodes.

Examine factors with the client that may be causing frequent hypoglycemic episodes. Hypoglycemic reactions present as adrenergic symptoms of tremor, shakiness, and nervousness that are comparable or alike to the signs of alcohol intoxication. The best strategy to assist the client to meet his needs is to decrease the episodes of hypoglycemia by first identifying and then eliminating those factors that precipitate this event. Asking the client if he has been drinking at work and contacting the local employment office are inappropriate. Asking the client what he does to treat his hypoglycemia is not directly related to the subject, factors that may cause frequent hypoglycemic episodes.

A 3-month-old female develops colicky pain, abdominal distention, and diarrhea after drinking cow's milk. The best explanation for her symptoms is:

Excess of undigested lactose in her digestive tract, resulting in increased fluid movement into the digestive lumen and increased bowel motility Response Feedback: Undigested lactose increases the osmotic gradient in the intestine, causing irritation and osmotic diarrhea.

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? 1. Strain 2. Sprain 3. Fracture 4. Contusion

Fracture Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign or symptom. A strain results from a pulling force on the muscle, resulting in soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion and is manifested by pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.

A client with type 2 diabetes mellitus is complaining of polydipsia, polyuria, weight loss, and weakness. Laboratory results indicate a blood glucose level of 800 mg/dL (45.7 mmol/L) and nonketosis. The nurse reviews the health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia\ 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

Hyperosmolar hyperglycemic syndrome (HHS) HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. In HHS, the client is nonketotic. The clinical manifestations noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical manifestations. DKA typically occurs in type 1 diabetes mellitus.

A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

Hyperosmolar hyperglycemic syndrome (HHS) HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. The clinical manifestations noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical manifestations. DKA typically occurs in type 1 diabetes mellitus.

A client has been diagnosed with pheochromocytoma. Which clinical manifestation is most indicative of this condition? 1. Water loss 2. Bradycardia 3. Hypertension 4. Decreased cardiac output

Hypertension 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.

A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse should assess for which sign or symptom? 1. Bradycardia 2. Constipation 3. Hypertension 4. Low-grade temperature

Hypertension Thyroid storm is an acute, life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Clinical manifestations of thyroid storm include systolic hypertension, tachycardia, diarrhea, and a fever as high as 106°F. Other manifestations include abdominal pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial fibrillation, and cardiovascular collapse. Bradycardia, constipation and low-grade temperature are not a part of the clinical picture in thyroid storm.

A client has begun medication therapy with propylthiouracil. The nurse should assess the client for which condition as an adverse effect of this medication? 1. Joint pain 2. Renal toxicity 3. Hyperglycemia 4. Hypothyroidism

Hypothyroidism Propylthiouracil is prescribed for the treatment of hyperthyroidism. Excessive dosing with this agent may convert a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required to treat the hypothyroid state. Propylthiouracil is not used for relief of joint pain. It does not cause renal toxicity or hyperglycemia.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

IV fluids containing dextrose Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast? 1. The cast gives off heat as it dries. 2. The client can bear weight on the cast in 1 hour. 3. A stockinette and soft padding are put over the leg area before casting. 4. Immediately report any increase in drainage or interruption in cast integrity.

Immediately report any increase in drainage or interruption in cast integrity. Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? 1. Take a set of vital signs. 2. Call the radiology department. 3. Reassure the client that everything will be fine. 4. Immobilize the right leg before moving the client.

Immobilize the right leg before moving the client. When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a health care provider is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiographs. Telling the client that everything will be fine is nontherapeutic. Although vital signs will be taken, the priority is to immobilize the leg.

Manifestations associated with hepatic encephalopathy from chronic liver disease are the result of:

Impaired ammonia metabolism Response Feedback: Impaired ammonia metabolism leads to the symptoms of hepatic encephalopathy.

The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? 1. Open 2. Displaced 3. Complete 4. Incomplete

Incomplete An incomplete fracture is one that extends through only part of the thickness of the bone. These fractures usually are nondisplaced, meaning that the bone remains in the normal position. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tissue. A complete fracture is one that extends through the full thickness of bone and often is displaced, meaning that the bone moves out of normal position.

A 60-year-old male presents with GI bleeding and abdominal pain. He reports that he takes NSAIDs daily to prevent heart attack. Tests reveal that he has a peptic ulcer. The most likely cause of this disease is:

Inhibiting mucosal prostaglandin synthesis Response Feedback: Use of NSAIDs inhibit prostaglandins and maintenance of the mucosal barrier and decrease bicarbonate secretion.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

Injury to the brachial plexus nerves Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? 1. Ensure that the weight used as a pulling force is at least 20 lb (9 kg). 2. Ensure that the weights rest on the floor and are not freely hanging. 3. Inspect the skin at least every 8 hours for signs of irritation or inflammation. 4. Remove the weights for at least 5 minutes every hour to give the client a rest

Inspect the skin at least every 8 hours for signs of irritation or inflammation. It is important for the skin to be assessed at least every 8 hours. Weights should be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and should always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? 1. It is strained. 2. It is contused. 3. It has completely dislocated. 4. It has incompletely dislocated.

It has incompletely dislocated. A dislocation is the disruption of a joint to the extent that the articulating surfaces are no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces. Because the disruption is less severe, healing time is less prolonged. A strain occurs when a muscle or ligament is used beyond the limit of its functional ability. It is characterized by overstretching of the muscle or ligament and also could involve tearing if the strain is more severe (i.e., second- or third-degree strain versus first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into the involved tissue.

The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information? 1. It indicates nerve damage. 2. The hoarseness is permanent. 3. It is normal during this time and will subside. 4. It will worsen before it subsides, which may take 6 months.

It is normal during this time and will subside. Hoarseness in the postoperative period usually is the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. The other options are incorrect.

A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should assess which area as high risk for pressure and breakdown? 1. Left heel 2. Scapulae 3. Right heel 4. Back of the head

Left heel Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. Scapulae and the back of the head are not common areas for pressure ulcers for this client. The right heel is elevated because of traction.

The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? 1. Wear the sling at nighttime. 2. Keep a sling on the arm at all times. 3. Avoid range-of-motion exercises to the affected arm. 4. Lift the shoulder of the casted arm over the head periodically throughout the day.

Lift the shoulder of the casted arm over the head periodically throughout the day. A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client should not keep a sling on the arm at all times or wear the sling at nighttime. Range-of-motion exercises to the casted extremity would assist in preventing this complication.

Which of the following symptoms would help a health care provider distinguish between ulcerative colitis and Crohn disease?

Malabsorption Response Feedback: Malabsorption is common in Crohn disease and is rare in ulcerative colitis.

A nurse is teaching a prenatal class and is talking about environmental factors that affect the development of a fetus's neural tube. Which information should the nurse include in the teaching session? Select all that apply.

Maternal nutrition, Maternal Infection, Folic acid deficiency, Alcohol consumption by the mother.

The nurse is caring for a client who is 2 days postoperative from abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin based on capillary blood glucose testing 4 times a day. A carbohydrate-controlled diet has been prescribed, but the client has not been eating. On entering the client's room, the nurse finds the client to be pale and diaphoretic. Which action is appropriate at this time? 1. Call a code to obtain needed assistance immediately. 2. Obtain a capillary blood glucose level and quickly perform a focused assessment. 3. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining a carbohydrate snack for the client to eat. 4. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

Obtain a capillary blood glucose level and quickly perform a focused assessment. Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change in condition could be related to the administration of insulin without the client's eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and quickly perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the UAP to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? 1. pH 2. Pao2 3. HCO3 4. Paco2

Pao2 A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2 often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results.

A 62-year-old male presents with difficulty swallowing. Tests reveal a loss of esophageal peristalsis and failure of the lower esophageal sphincter to relax. Functional dysphasia is the diagnosis. A history of which of the following could be the most likely cause? (Select all that apply.)

Parkinson disease Cerebrovascular accident Achalasia Functional dysphasia is caused by neural or muscular disorders that interfere with voluntary swallowing or peristalsis. Disorders that affect the striated muscles of the upper esophagus interfere with the oropharyngeal (voluntary) phase of swallowing. Typical causes are dermatomyositis (a muscle disease) and neurologic impairments caused by cerebrovascular accidents, Parkinson disease, or achalasia. Peptic ulcer disease or pyloric stenosis would not cause functional dysphasia.

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? 1. Apply ice to the affected area. 2. Perform sterile dressing changes. 3. Instruct the client on leg exercises. 4. Measure the leg circumference daily.

Perform sterile dressing changes. Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg circumference daily, is not necessary.

A nurse is assessing a client who has had cranial surgery and is at risk for development of diabetes insipidus. The nurse would assess for which signs or symptoms that could indicate development of this complication? 1. Diarrhea 2. Infection 3. Polydipsia 4. Weight gain

Polydipsia Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Diarrhea is not indicative of the complication. Infection is not associated with diabetes insipidus. Anorexia and weight loss also may occur.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate

Polyuria Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.

A nurse is assessing the glycemic status of a client with diabetes mellitus. Which sign or symptom would indicate that the client is developing hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

Polyuria Classic signs and symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. It is important to regularly assess the client for hyperglycemia to prevent the development of more serious complications, such as diabetic ketoacidosis. The remaining options are not manifestations of hyperglycemia.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

Presence of a "hot spot" on the cast Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? 1. Glyburide via the oral route 2. Glucagon via the subcutaneous route 3. Insulin aspart via the subcutaneous route 4. Regular insulin via the intravenous (IV) route

Regular insulin via the intravenous (IV) route The client is most likely in diabetic ketoacidosis (DKA). Regular insulin via the IV route is the preferred treatment for DKA. Regular insulin is a short-acting insulin and can be given intravenously; it is titrated to the client's high blood glucose levels. Glucagon is used to treat hypoglycemia, and glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus. Insulin aspart is a short-acting insulin and is not appropriate for the emergency treatment of DKA.

The nurse in a health care clinic is reviewing the record of a client with diabetes mellitus who was just seen by the health care provider (HCP). The nurse notes that the HCP has prescribed acarbose. Which preexisting disorder, if noted in the client's record, would indicate a contraindication to the use of this medication? 1. Hypothyroidism 2. Renal insufficiency 3. Arterial insufficiency 4. Coronary artery disease

Renal insufficiency Acarbose is an antidiabetic medication that may be administered alone or in conjunction with another antidiabetic medication. It is contraindicated in clients with significant renal dysfunction. It also is contraindicated in clients with inflammatory bowel disease, colonic ulceration, or partial intestinal obstruction.

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

Respiratory distress Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.

A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? 1. Diarrhea 2. Constipation 3. Double vision 4. Ringing in the ears

Ringing in the ears Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because a salicylate stimulates the respiratory center. Fever may result because a salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. The remaining options are not signs of aspirin toxicity.

A nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. The nurse should ask the client if which measure is taken? 1. Rotating sites for injection 2. Administering the insulin at a 45-degree angle 3. Cleaning the skin with alcohol before each injection 4. Aspirating for blood before injection into the subcutaneous tissue

Rotating sites for injection Lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs in some clients with diabetes mellitus when injection sites are used for a prolonged period. Therefore, clients are instructed to adhere to a plan of rotating injection sites to avoid tissue changes. Angle of insulin administration, cleansing with alcohol, and aspiration do not produce this complication.

A client with type 1 diabetes mellitus is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). Which laboratory result would be expected with this diagnosis? 1. Urine is negative for ketones. 2. Serum potassium is 6.8 mEq/L (6.8 mmol/L). 3. Serum osmolality is 260 mOsm/kg (260 mmol/kg) H20. 4. Arterial blood gas values are pH 7.52, PCO2 44 mm Hg, HCO3- 30 mEq/L (30 mmol/L).

Serum potassium is 6.8 mEq/L (6.8 mmol/L). Movement of hydrogen ions from the extracellular to the intracellular fluid promotes the movement of potassium from intracellular to extracellular fluid. Thus, the serum potassium level will rise. The value in option 2 is greater than the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The presence of ketones in urine would be expected, and the serum osmolality would be elevated to reflect dehydration (the serum osmolality in option 3 is decreased). The client with DKA experiences metabolic acidosis (not metabolic alkalosis as noted in option 4).

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? 1. Agitation 2. Diaphoresis 3. Restlessness 4. Severe abdominal pain

Severe abdominal pain Addisonian crisis is a serious life-threatening response to acute adrenal insufficiency that most commonly is precipitated by a major stressor. The client in addisonian crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. The remaining options do not identify clinical manifestations associated with addisonian crisis.

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

Signs of skin breakdown Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can result from immobility, and although monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? 1. Age of onset is generally 65 years of age or older 2. Complaints of pain that is more severe after activity 3. Systemic symptoms such as fatigue, anorexia, and weight loss 4. Joint pain is asymmetrical and associated with past injuries to the joint

Systemic symptoms such as fatigue, anorexia, and weight loss In clients diagnosed with RA, systemic symptoms such as fatigue, anorexia, weight loss, and nonspecific aching and stiffness may appear before joint manifestations. RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The age of onset for RA is most commonly between 30 and 50 years of age. Complaints of pain that is more severe after activity and asymmetrical joint pain associated with past injuries to the joint are more commonly seen in osteoarthritis.

The nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which behavior indicates to the nurse that the client is not ready to learn? 1. The client asks if the spouse may attend the teaching session. 2. The client asks appropriate questions about what will be taught. 3. The client asks for written materials about diabetes mellitus before class. 4. The client complains of fatigue whenever the nurse plans a teaching session.

The client complains of fatigue whenever the nurse plans a teaching session. Physical symptoms can interfere with an individual's ability to learn and can indicate to the teacher that the student lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. The remaining options identify active client participation in learning.

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? 1. The client needs immediate education before discharge. 2. The client requires follow-up teaching regarding the administration of oral antidiabetics. 3. The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. 4. The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.

The client needs immediate education before discharge. If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the HCP should be notified. The client's statement indicates a need for immediate education to prevent hyperosmolar hyperglycemic syndrome (HHS), a life-threatening emergency. Although all of the other options may be true, the most appropriate analysis is that the client requires immediate education.

The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the discussion with the client? 1. The brace should be applied directly next to the skin. 2. The device is applied before getting out of bed in the morning. 3. The self-adhering closures should be fairly loose to avoid constriction. 4. Areas of skin redness at the edges of the brace indicate a good, snug fit.

The device is applied before getting out of bed in the morning. After spinal surgery, a brace or corset may be required temporarily to support the spine. Clients who have lumbar or thoracic spinal fusions wear a fiberglass brace, which resembles a shell. Initially, back braces or corsets may be worn constantly, whether the client is in or out of bed. If not required constantly, the brace is applied in the morning before getting out of bed. As the client's muscles strengthen, the use of braces or corsets is usually decreased. A back brace or thoracolumbosacral orthosis is individually fitted to the client. A layer of clothing is worn between the orthosis and the skin. The closures should be secure but not overly loose or tight. The brace should not irritate the skin with proper fitting. Always follow the health care provider's activity prescriptions.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

Thick, yellow drainage from the pin sites The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.

A client newly diagnosed with diabetes mellitus is started on a 2-dose insulin protocol combination of short- and intermediate-acting insulin injected twice daily. What portion of the total dose is given before breakfast, and what portion is given before the evening meal? 1. Half before breakfast and half before the evening meal 2. Two thirds before breakfast and one third before the evening meal 3. One third before breakfast and two thirds before the evening meal 4. Three fourths before breakfast and one fourth before the evening meal

Two thirds before breakfast and one third before the evening meal Initially the 2-dose insulin protocol is two thirds of the dose before breakfast and one third before the evening meal. Any future changes in these ratios are based on results of blood glucose monitoring. Therefore, the remaining options are incorrect amounts.

The nurse has taught a client with a below-the-knee amputation about prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client makes which statement? 1. Wear a clean nylon residual limb sock daily. 2. Use a mirror to inspect all areas of the residual limb each day. 3. Toughen the skin of the residual limb by rubbing it with alcohol. 4. Prevent cracking of the skin of the residual limb by applying lotion daily.

Use a mirror to inspect all areas of the residual limb each day. Following amputation, the client should inspect all surfaces of the residual limb daily for irritation, blisters, or breakdown. The other options are incorrect. The client should wear a clean woolen residual limb sock each day. Nylon is a synthetic material that does not allow the best air circulation and holds in moisture. The stump is cleansed daily with a gentle soap and water and is dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils, creams, and lotions also are avoided because they are too softening to the skin for safe prosthesis use.

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? 1. Use a raised toilet seat. 2. Bend carefully to put on socks and shoes. 3. Sit in chairs without arms for better mobility. 4. Exercise the leg past the point of 90-degree flexion.

Use a raised toilet seat. The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. The client should sit in chairs that have arms to provide assistance in rising from the sitting position. The client also should maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees.

The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

Vital signs Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant: a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight.

a. Raises the head, and arches the back. At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

a. Ask the patient to lock her fingers and pull. Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the persons position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: a. Called hypospadias. b. A result of phimosis. c. Probably due to a stricture. d. Often associated with aging.

a. Called hypospadias. Normally, the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.

During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition? a. Candidiasis b. Trichomoniasis c. Atrophic vaginitis d. Bacterial vaginosis

a. Candidiasis The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike. Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge. Bacterial vaginosis causes a profuse discharge that has a foul, fishy, rotten odor. Atrophic vaginitis may have a mucoid discharge. (See Table 26-5 for complete descriptions of each option.)

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

a. Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a persons level of consciousness.

Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man? a. Do you need to get up at night to urinate? b. Do you experience nocturnal emissions, or wet dreams? c. Do you know how to perform a testicular self-examination? d. Has anyone ever touched your genitals when you did not want them to?

a. Do you need to get up at night to urinate? The older male patient should be asked about the presence of nocturia. Awaking at night to urinate may be attributable to a diuretic medication, fluid retention from mild heart failure or varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The other questions are more appropriate for younger men.

During an examination, which tests will the nurse collect to screen for cervical cancer? a. Endocervical specimen, cervical scrape, and vaginal pool b. Endocervical specimen, vaginal pool, and acetic acid wash c. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid wash d. Cervical scrape, acetic acid wash, saline mount (wet prep)

a. Endocervical specimen, cervical scrape, and vaginal pool Laboratories may vary in method, but usually the test consists of three specimens: endocervical specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation, and saline mount) are used to test for sexually transmitted infections.

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make funny faces at the nurse.

a. Hop on one foot. Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make funny faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

a. Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

a. Parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)

During a physical examination, the nurse finds that a male patients foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: a. Phimosis. b. Epispadias. c. Urethral stricture. d. Peyronie disease.

a. Phimosis. With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over the glans. This condition may be congenital or acquired from adhesions related to infection. (See Table 24-3 for information on urethral stricture. See Table 24-4 for information on epispadias and Peyronie disease.)

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infants cries are very high pitched and shrill. What should be the nurses appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

a. Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parents report of significant changes in behavior all warrant referral. The other options are not correct responses.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

a. Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be attributable to: a. Side effects of medications. b. Decreased libido with aging. c. Decreased sperm production. d. Decreased pleasure from sexual intercourse.

a. Side effects of medications. In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics, tranquilizers or narcotics, and estrogens. The other options are not correct.

The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation? a. Skin on the scrotum is taut. b. Left testicle hangs lower than the right testicle. c. Scrotal skin has yellowish 1-cm nodules that are firm and non-tender. d. Testes move closer to the body in response to cold temperatures.

a. Skin on the scrotum is taut. Scrotal swelling may cause the skin to be taut and to display pitting edema. Normal scrotal skin is rugae, and asymmetry is normal with the left scrotal half usually lower than the right. The testes may move closer to the body in response to cold temperatures.

A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the following assessment findings support this diagnosis? Select all that apply. a. Swollen testis b. Mass that transilluminates c. Mass that does not transilluminate d. Scrotum that is nontender upon palpation e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened

a. Swollen testis c. Mass that does not transilluminate e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened With orchitis, the testis is swollen, with a feeling of weight, and is tender or painful. The mass does not transilluminate, and the scrotal skin is reddened. Transillumination of a mass occurs with a hydrocele, not orchitis.

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman? a. The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. b. Once a woman reaches menopause, the nurse does not need to ask any history questions. c. The nurse should screen for monthly breast tenderness. d. Postmenopausal women are not at risk for contracting STIs; therefore, these questions can be omitted.

a. The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. Postmenopausal bleeding warrants further workup and referral. The other statements are not true.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

a. These findings are normal, resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

When assessing a newborn infants genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infants mother states that she is worried about the labia being swollen. The nurse should reply: a. This is a normal finding in newborns and should resolve within a few weeks. b. This finding could indicate an abnormality and may need to be evaluated by a physician. c. We will need to have estrogen levels evaluated to ensure that they are within normal limits. d. We will need to keep close watch over the next few days to see if the genitalia decrease in size.

a. This is a normal finding in newborns and should resolve within a few weeks. It is normal for a newborns genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.

An 11-year-old girl is in the clinic for a sports physical examination. The nurse notices that she has begun to develop breasts, and during the conversation the girl reveals that she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development? The nurse should: a. Use the Tanner scale on the five stages of sexual development. b. Describe her development and compare it with that of other girls her age. c. Use the Jacobsen table on expected development on the basis of height and weight data. d. Reassure her that her development is within normal limits and tell her not to worry about the next step.

a. Use the Tanner scale on the five stages of sexual development.

The corona is: a. a shoulder where the glans joins the shaft. b. a hood or flap of skin over the glans. c. a corpus spongiosum cone of erectile tissue. d. folds of thin skin on the scrotal wall.

a. a shoulder where the glans joins the shaft. The corona is a shoulder where the glans joins the shaft. Over the glans, the skin folds in and back on itself forming a hood or flap called the foreskin or prepuce. The penis is composed of three cylindrical columns of erectile tissue: two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. The scrotal wall consists of thin skin lying in folds, or rugae, and the underlying cremaster muscle.

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a: a. dermatome. b. dermal segmentation. c. hemisphere. d. crossed representation.

a. dermatome. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. Dermal segmentation is the cutaneous distribution of the various spinal nerves. Each half of the cerebrum is a hemisphere. Crossed representation is a feature of the nerve tracts; the left cerebral cortex receives sensory information from and controls motor function to the right side of body, whereas the right cerebral cortex likewise interacts with the left side of the body.

The first sign of puberty in boys is: a. enlargement of the testes. b. the appearance of pubic hair. c. an increase in penis size. d. pubic hair growth extending up the abdomen.

a. enlargement of the testes. The first sign of puberty in boys is enlargement of the testes. Following the enlargement of the testes, pubic hair appears, then penis size increases. Pubic hair growth extending up the abdomen occurs after puberty.

Automatic associated movements of the body are under the control and regulation of: a. the basal ganglia. b. the thalamus. c. the hypothalamus. d. Wernicke's area.

a. the basal ganglia. The basal ganglia controls automatic associated movements of the body. The thalamus is where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The hypothalamus is a major respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure control; sleep center; anterior and posterior pituitary gland regulation; and coordination of autonomic nervous system activity and stress response. Wernicke's area in the temporal lobe is associated with language comprehension.

The ejaculatory duct is: a. the passage formed by the joining of the vas deferens and the seminal vesicle. b. a muscular duct continuous with the epididymis. c. a narrow tunnel inferior to the inguinal ligament. d. a narrow tunnel superior to the inguinal ligament.

a. the passage formed by the joining of the vas deferens and the seminal vesicle. The ejaculatory duct is the passage formed by the junction of the duct of the seminal vesicles and the vas deferens through which semen enters the urethra. The muscular duct continuous with the epididymis is the vas deferens. The femoral canal is inferior to the inguinal ligament. The inguinal canal is superior to the inguinal ligament and is a narrow tunnel passing obliquely between layers of abdominal muscle.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

b. Astereognosis Stereognosis is the persons ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the persons ability to feel sensations on both sides of the body at the same point.

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: a. If you are menstruating, please use pads to avoid placing anything into the vagina. b. Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment. c. If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you. d. We would like you to use a mild saline douche before your examination. You may pick this up in our office.

b. Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment. When instructing a patient before Pap smear is obtained, the nurse should follow these guidelines: Do not obtain during the womans menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.

Vaginal lubrication during intercourse is produced by: a. Skene glands. b. Bartholin glands. c. sebaceous glands. d. adrenal glands.

b. Bartholin glands. The vestibular (Bartholin) glands secrete a clear lubricating mucus during intercourse. Paraurethral (Skene) glands are tiny, multiple glands that surround the urethral meatus. Sebaceous glands are microscopic glands in the skin that secrete an oily/waxy matter, called sebum, to lubricate the skin and hair. The adrenal glands are endocrine glands responsible for releasing hormones in conjunction with stress through the synthesis of corticosteroids and catecholamines.

Multi-Response: A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying Im just getting old! After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood

b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in ones own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. Does your family know you are drinking every day? b. Does the tremor change when you drink alcohol? c. Well do some tests to see what is causing the tremor. d. You really shouldnt drink so much alcohol; it may be causing your tremor.

b. Does the tremor change when you drink alcohol? Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

During the examination portion of a patients visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her? a. Ask her to place her hands and arms over her head. b. Elevate her head and shoulders to maintain eye contact. c. Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. d. Allow her to keep her buttocks approximately 6 inches from the edge of the table to prevent her from feeling as if she will fall off.

b. Elevate her head and shoulders to maintain eye contact. The nurse should elevate her head and shoulders to maintain eye contact. The patients arms should be placed at her sides or across the chest. Placing her hands and arms over her head only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. The stirrups are placed so that the legs are not abducted too far.

A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these? a. Varicocele b. Epididymitis c. Spermatocele d. Testicular torsion

b. Epididymitis Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The epididymis is enlarged and indurated and may be hard to distinguish from the testis. The overlying scrotal skin may be thick and edematous. (See Table 24-6 for more information and for the descriptions of the other terms.)

When the nurse is discussing sexuality and sexual issues with an adolescent, a permission statement helps convey that it is normal to think or feel a certain way. Which statement is the best example of a permission statement? a. It is okay that you have become sexually active. b. Girls your age often have questions about sexual activity. Do you have any questions? c. If it is okay with you, Id like to ask you some questions about your sexual history. d. Girls your age often engage in sexual activities. It is okay to tell me if you have had intercourse.

b. Girls your age often have questions about sexual activity. Do you have any questions? The examiner should start with a permission statement such as, Girls your age often experience A permission statement conveys the idea that it is normal to think or feel a certain way, and implying that the topic is normal and unexceptional is important.

The nurse is palpating a female patients adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurses most appropriate course of action would be to: a. Tell the patient that her examination is normal. b. Give her an immediate referral to a gynecologist. c. Suggest that she return in a month for a recheck to verify the findings. d. Tell the patient that she may have an ovarian cyst that should be evaluated further.

b. Give her an immediate referral to a gynecologist. Normally, the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not normally palpable. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral.

A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she started 3 months earlier. The nurse should tell her: a. HRT is at such a low dose that side effects are very unusual. b. HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding. c. Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic immediately to have this evaluated. d. It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week.

b. HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding.

A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? A postmenopausal woman: a. Is not at any greater risk for heart disease than a younger woman. b. Should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions. c. Has only stopped menstruating; there really are no other significant changes with which she should be concerned. d. Is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle.

b. Should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions.

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. A good time to examine your testicles is just before you take a shower. b. If you notice an enlarged testicle or a painless lump, call your health care provider. c. The testicle is egg shaped and movable. It feels firm and has a lumpy consistency. d. Perform a testicular examination at least once a week to detect the early stages of testicular cancer.

b. If you notice an enlarged testicle or a painless lump, call your health care provider. If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, then he should call his health care provider for further evaluation. The testicle normally feels rubbery with a smooth surface. A good time to examine the testicles is during the shower or bath, when ones hands are warm and soapy and the scrotum is warm. Testicular self-examination should be performed once a month

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

b. Increased intracranial pressure In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

b. Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

Multiple Response The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the masss characteristics would suggest the presence of an ovarian cyst? Select all that apply. a. Heavy and solid b. Mobile and fluctuant c. Mobile and solid d. Fixed e. Smooth and round f. Poorly defined

b. Mobile and fluctuant e. Smooth and round An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

b. Motor component of CN VII The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infants sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

The nurse knows that testing kinesthesia is a test of a persons: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

b. Position sense. Kinesthesia, or position sense, is the persons ability to perceive passive movements of the extremities. The other options are incorrect.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

b. Positive Babinski sign, which is abnormal for adults Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

The external male genital structures include the: a. Testis. b. Scrotum. c. Epididymis. d. Vas deferens.

b. Scrotum. The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures.

When assessing the scrotum of a male patient, the nurse notices the presence of multiple firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely: a. From urethritis. b. Sebaceous cysts. c. Subcutaneous plaques. d. From an inflammation of the epididymis.

b. Sebaceous cysts. Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm, nontender, and often multiple. The other options are not correct.

When performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow with transillumination. On the basis of this finding the nurse would: a. Assess the patient for the presence of a hernia. b. Suspect the presence of serous fluid in the scrotum. c. Consider this finding normal, and proceed with the examination. d. Refer the patient for evaluation of a mass in the scrotum.

b. Suspect the presence of serous fluid in the scrotum. Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.

The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: a. Puberty usually begins around 15 years of age. b. The first sign of puberty is an enlargement of the testes. c. The penis size does not increase until about 16 years of age. d. The development of pubic hair precedes testicular or penis enlargement.

b. The first sign of puberty is an enlargement of the testes. Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis size increases.

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

b. The hypothalamus controls body temperature and regulates sleep. The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

A retention cyst in the epididymis filled with milky fluid containing sperm is called: a. a varicocele. b. a spermatocele. c. Peyronie disease. d. a prepuce.

b. a spermatocele. A spermatocele is a retention cyst in the epididymis filled with milky fluid containing sperm. A varicocele is a dilated, tortuous varicose vein in the spermatic cord. Peyronie disease is a result of hard, nontender, subcutaneous plaques on the penis that cause a painful bending of the penis during an erection. Over the glans, the skin folds in and back on itself forming a hood or flap called the foreskin or prepuce.

The _____________ reflex is an example of a __________ reflex. a. plantar; deep tendon b. abdominal; superficial c. quadriceps; pathologic d. corneal light; visceral

b. abdominal; superficial Superficial reflexes test the sensory receptor in the skin; the motor response is a localized muscle contraction. Superficial reflexes include abdominal, cremasteric, and plantar (or Babinski) reflexes. Deep tendon reflexes test the reflex arc at the spinal level and include the biceps, triceps, brachioradialis, quadriceps, and Achilles. The quadriceps reflex is a deep tendon reflex and is normal. The corneal light reflex assesses the parallel alignment of the eye (cranial nerves III, IV, and VI).

Hematuria is a term used for: a. bloody discharge. b. blood in the urine. c. bleeding after intercourse. d. urine in the blood.

b. blood in the urine. Hematuria is the term used to describe blood in the urine.

Soft, pointed, fleshy papules that occur on the genitalia caused by human papillomavirus (HPV) are known as: a. chancres. b. genital warts. c. urethritis. d. varicoceles.

b. genital warts. Condylomata acuminata (genital warts) are soft, pointed, fleshy papules that occur on the genitalia and are caused by HPV. Syphilitic chancres are small, solitary, silvery papules that erode to a red, round or oval, superficial ulcer with a yellowish serous discharge. Urethritis is an infection of the urethra; the meatus edges are reddened, everted, and swollen. A varicocele is a dilated, tortuous varicose vein in the spermatic cord.

Cessation of menses is known as: a. menarche. b. menopause. c. salpingitis. d. adnexa.

b. menopause. Menopause is the cessation of menses. Menarche is the age of the first period. Salpingitis is inflammation of the fallopian tube. The adnexa of uterus (or uterine appendages) refers to the structures most closely related structurally and functionally to the uterus; these structures include the ovaries, fallopian tubes, and ligaments.

Cerebellar function is tested by: a. muscle strength assessment. b. performance of rapid alternating movements. c. the Phalen maneuver. d. superficial pain and touch assessment.

b. performance of rapid alternating movements. The cerebellum controls motor coordination of voluntary movements, equilibrium, and muscle tone. Cerebellar function is tested by balance tests (e.g., gait, Romberg test) and coordination and skilled movements (e.g., rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test). Muscle strength assessment examines the intactness of the motor system. The Phalen maneuver reproduces numbness and burning in a patient with carpal tunnel syndrome. Superficial pain and touch assessment examines intactness of the spinothalamic tract.

A caruncle is a(n): a. vestibular gland located on either side of the vaginal orifice. b. small, red mass protruding from the urethral meatus. c. aberrant growth of endometrial tissue. d. hard, painless nodule in the uterine wall.

b. small, red mass protruding from the urethral meatus. A caruncle is a small, deep red mass protruding from the urinary meatus. Bartholin glands are vestibular glands located on either side of and posterior to the vaginal orifice. Endometriosis is a disorder caused by aberrant growths of endometrial tissue scattered throughout the pelvis. Myomas (leiomyomas or uterine fibroids) is a disorder in which the uterus is irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurses finger, then his own nose, then the nurses finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

c. Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The persons movements should be smooth and accurate. The other options are not correct.

What term is used to describe involuntary muscle movements? a. Ataxia b. Flaccid c. Athetosis d. Vestibular function

c. Athetosis Athetosis is slow, writhing, continuous, and involuntary movements of the extremities. Ataxia is an impaired ability to coordinate movement, often characterized by a staggering gait and postural imbalance. Flaccid is weak, soft, and flabby; lacking normal muscle tone. Vestibular function is the sense of balance.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

c. Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) ______ hernia. a. Scrotal b. Femoral c. Direct inguinal d. Indirect inguinal

c. Direct inguinal Direct inguinal hernias occur most often in men over the age of 40 years. It is an acquired weakness brought on by heavy lifting, obesity, chronic cough, or ascites. The direct inguinal hernia is usually a painless, round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. (See Table 24-6 for a description of scrotal hernia. See Table 24-7 for the descriptions of femoral hernias and indirect inguinal hernias.)

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

c. Dysfunction of the cerebellum When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are: a. Peyronie disease. b. Genital warts. c. Genital herpes. d. Syphilitic cancer.

c. Genital herpes. Genital herpes, or herpes simplex virus 2 (HSV-2), infections are indicated with clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin. (See Table 24-4 for the descriptions of the other options.)

During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be: a. Syphilitic chancre. b. Herpes simplex virus type 2 (herpes genitalis). c. HPV or genital warts. d. Pediculosis pubis (crab lice).

c. HPV or genital warts. HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or flesh colored, soft, pointed, moist, warty papules that occur in single or multiple cauliflower-like patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary silvery papule that erodes into a red, round or oval superficial ulcer with a yellowish discharge. Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas (see Table 26-2).

During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurses most appropriate response to this would be: a. Oh, dont worry. Some cyclic vaginal discharge is normal. b. Have you been engaging in unprotected sexual intercourse? c. I'd like some information about the discharge. What color is it? d. Have you had any urinary incontinence associated with the discharge?

c. I'd like some information about the discharge. What color is it?

The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? a. Bimanual, speculum, and rectovaginal b. Speculum, rectovaginal, and bimanual c. Speculum, bimanual, and rectovaginal d. Rectovaginal, bimanual, and speculum

c. Speculum, bimanual, and rectovaginal The correct sequence is speculum examination, then bimanual examination after removing the speculum, and then rectovaginal examination. The examiner should change gloves before performing the rectovaginal examination to avoid spreading any possible infection.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

c. Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

c. Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

The nurse is aware of which statement to be true regarding the incidence of testicular cancer? a. Testicular cancer is the most common cancer in men aged 30 to 50 years. b. The early symptoms of testicular cancer are pain and induration. c. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer. d. The cure rate for testicular cancer is low.

c. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer Men with undescended testicles (cryptorchidism) are at the greatest risk for the development of testicular cancer. The overall incidence of testicular cancer is rare. Although testicular cancer has no early symptoms, when detected early and treated before metastasizing, the cure rate is almost 100%.

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

c. Normal changes attributable to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: a. Ovarian cyst. b. Endometriosis. c. Ovarian cancer. d. Ectopic pregnancy.

c. Ovarian cancer. Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular, and tender to palpation, with enlarged ovaries.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

c. Presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the persons ability to perceive passive movement of the extremities or the loss of position sense.

An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate? a. Inviting her mother to be present during the examination b. Avoiding the lithotomy position for this first time because it can be uncomfortable and embarrassing c. Raising the head of the examination table and giving her a mirror so that she can view the examination d. Fully draping her, leaving the drape between her legs elevated to avoid embarrassing her with eye contact

c. Raising the head of the examination table and giving her a mirror so that she can view the examination The techniques of the educational or mirror pelvic examination should be used. This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiners hands. The young woman can see all that the examiner is doing and has a full view of her genitalia. The mirror works well for teaching normal anatomy and its relationship to sexual behavior. The examiner can ask her if she would like to have a family member, friend, or chaperone present for the examination. The drape should be pushed down between the patients legs so that the nurse can see her face.

A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup. How would the nurse proceed with the genital examination? a. Eliciting the cremasteric reflex is recommended. b. The glans is assessed for redness or lesions. c. Retracting the foreskin should be avoided until the infant is 3 months old. d. Any dirt or smegma that has collected under the foreskin should be noted.

c. Retracting the foreskin should be avoided until the infant is 3 months old. If uncircumcised, then the foreskin is normally tight during the first 3 months and should not be retracted because of the risk of tearing the membrane attaching the foreskin to the shaft. The other options are not correct.

A 45-year-old mother of two children is seen at the clinic for complaints of losing my urine when I sneeze. The nurse documents that she is experiencing: a. Urinary frequency. b. Enuresis. c. Stress incontinence. d. Urge incontinence.

c. Stress incontinence. Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs as a result to weakness of the pelvic floor. Urinary frequency is urinating more times than usual (more than five to six times per day). Enuresis is involuntary passage of urine at night after age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive detrusor muscle in the bladder. It contracts, causing an urgent need to void.

During an examination, the nurse notices that a male patient has a red, round, superficial ulcer with a yellowish serous discharge on his penis. On palpation, the nurse finds a nontender base that feels like a small button between the thumb and fingers. At this point the nurse suspects that this patient has: a. Genital warts. b. Herpes infection. c. Syphilitic chancre. d. Carcinoma lesion.

c. Syphilitic chancre. This lesion indicates syphilitic chancre, which begins within 2 to 4 weeks of infection. (See Table 24-4 for the descriptions of the other options.)

When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? a. Non-tender subcutaneous plaques b. Scrotal area that is dry, scaly, and nodular c. Testes that feel oval and movable and are slightly sensitive to compression d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes

c. Testes that feel oval and movable and are slightly sensitive to compression Testes normally feel oval, firm and rubbery, smooth, and bilaterally equal and are freely movable and slightly tender to moderate pressure. The scrotal skin should not be dry, scaly, or nodular or contain subcutaneous plaques. Any mass would be an abnormal finding.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

The nurse is examining a 35-year-old female patient. During the health history, the nurse notices that she has had two term pregnancies, and both babies were delivered vaginally. During the internal examination, the nurse observes that the cervical os is a horizontal slit with some healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical surface is granular and red, especially around the os. Finally, the nurse notices the presence of stringy, opaque, odorless secretions. Which of these findings are abnormal? a. Nabothian cysts are present. b. The cervical os is a horizontal slit. c. The cervical surface is granular and red. d. Stringy and opaque secretions are present.

c. The cervical surface is granular and red. Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally smooth, but cervical eversion, or ectropion, may occur where the endocervical canal is rolled out. Abnormal finding: The cervical surface should not be reddened or granular, which may indicate a lesion.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations.

During an internal examination of a womans genitalia, the nurse will use which technique for proper insertion of the speculum? a. The woman is instructed to bear down, the speculum blades are opened and applied in a swift, upward movement. b. The blades of the speculum are inserted on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. The woman is asked to bear down after the speculum is inserted. c. The woman is instructed to bear down, the width of the blades are horizontally turned, and the speculum is inserted downward at a 45-degree angle toward the small of the woman's back. d. The blades are locked open by turning the thumbscrew. Once the blades are open, pressure is applied to the introitus and the blades are inserted downward at a 45-degree angle to bring the cervix into view.

c. The woman is instructed to bear down, the width of the blades are horizontally turned, and the speculum is inserted downward at a 45-degree angle toward the small of the woman's back. The examiner should instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the womans back. (See the text under Speculum Examination for more detail.)

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

c. This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. Which statement does the nurse know to be correct regarding ovarian cancer? a. Ovarian cancer rarely has any symptoms. b. The Pap smear detects the presence of ovarian cancer. c. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. d. Women over age 40 years should have a thorough pelvic examination every 3 years.

c. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms; or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for developing it.

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? a. Now, it is time to talk about your sexual history. When did you first have intercourse? b. Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now? c. Women often have questions about their sexual relationship and how it affects their health. Do you have any questions? d. Most women your age have had more than one sexual partner. How many would you say you have had?

c. Women often have questions about their sexual relationship and how it affects their health. Do you have any questions? The nurse should begin with an open-ended question to assess individual needs.

During assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occurs. This response indicates: a. that the patient needs to be referred for a more complete eye examination. b. a disease of the vestibular system, further evaluation is needed. c. an expected movement of the eyes during this procedure. d. this assessment should be repeated in 15 minutes to allow the eyes to rest.

c. an expected movement of the eyes during this procedure. Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

An abnormal sensation of burning or tingling is best described as: a. paralysis. b. paresis. c. paresthesia. d. paraphasia.

c. paresthesia. Paresthesia is an abnormal sensation such as burning or tingling. Paralysis is a loss of motor function as a result of a lesion in the neurologic or muscular system or loss of sensory innervation. Paresis is a partial or incomplete paralysis. Paraphasia is a condition in which a person hears and comprehends words but is unable to speak correctly; incoherent words are substituted for intended words.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: a. corticospinal tract. b. medulla. c. reflex arc at specific levels in the spinal cord. d. upper motor and lower motor neuron synaptic junction.

c. reflex arc at specific levels in the spinal cord. Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels. The corticospinal tract is the higher motor system that permits very skilled and purposeful movements such as writing. The medulla contains all ascending and descending fiber tracts; it has vital autonomic centers for respiration, heart, and gastrointestinal function as well as nuclei for cranial nerves VIII through XII. The upper motor neurons are located within the central nervous system and influence or modify the lower motor neurons and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves.

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, How often do I need to have this Pap test done? Which reply by the nurse is correct? a. It depends. Do you smoke? b. A Pap test needs to be performed annually until you are 65 years of age. c. If you have two consecutive normal Pap tests, then you can wait 5 years between tests. d. After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years.

d. After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years. Cervical cancer screening with the Pap test continues annually until age 30 years. After age 21, regardless of sexual history or activity, women should be screened every 3 years until age 30, then every 5 years until age 65.

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: He cant even remember how to button his shirt. When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patients mental status and ability to follow directions.

d. Before testing, the nurse would assess the patients mental status and ability to follow directions. The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, They seem to come and go, primarily when I am trying to do something. I havent noticed them when Im sleeping. This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

d. Chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

d. Complete neurologic examination The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a persons level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

The nurse is performing a genital examination on a male patient and notices urethral drainage. When collecting urethral discharge for microscopic examination and culture, the nurse should: a. Ask the patient to urinate into a sterile cup. b. Ask the patient to obtain a specimen of semen. c. Insert a cotton-tipped applicator into the urethra. d. Compress the glans between the examiners thumb and forefinger, and collect any discharge.

d. Compress the glans between the examiners thumb and forefinger, and collect any discharge. If urethral discharge is noticed, then the examiner should collect a smear for microscopic examination and culture by compressing the glans anteroposteriorly between the thumb and forefinger. The other options are not correct actions.

When the nurse is performing a genital examination on a male patient, which action is correct? a. Auscultating for the presence of a bruit over the scrotum b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal ligament c. Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side When palpating for the presence of a hernia on the right side, the male patient is asked to shift his weight onto the left (unexamined) leg. Auscultating for a bruit over the scrotum is not appropriate. When palpating for lymph nodes, the horizontal chain is palpated. The inguinal canal should be palpated whether a bulge is present or not.

A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is: a. Pediculosis pubis. b. Contact dermatitis. c. HPV. d. Herpes simplex virus type 2.

d. Herpes simplex virus type 2. Herpes simplex virus type 2 exhibits clusters of small, shallow vesicles with surrounding erythema that erupt on the genital areas. Inguinal lymphadenopathy is also present. The woman reports local pain, dysuria, and fever. (See Table 26-2 for more information and the descriptions of the other conditions.)

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: a. Urgency. b. Dribbling. c. Frequency. d. Hesitancy.

d. Hesitancy. Hesitancy is trouble in starting the urine stream. Urgency is the feeling that one cannot wait to urinate. Dribbling is the last of the urine before or after the main act of urination. Frequency is urinating more often than usual.

When performing a genitourinary assessment on a 16-year-old male adolescent, the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down. The patient complains of pain when straining. The nurse knows that this description is most consistent with a(n) ______ hernia. a. Femoral b. Incisional c. Direct inguinal d. Indirect inguinal

d. Indirect inguinal With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with increased intra-abdominal pressure, which may decrease when the patient lies down. These findings do not describe the other hernias. (See Table 24-7 for the descriptions of femoral, direct inguinal, and indirect inguinal hernias.)

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patients response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

d. Is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

d. Moves the head and shoulders against resistance with equal strength. The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patients sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patients ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? a. Do you use condoms? b. You don't masturbate, do you? c. Have you had sex in the last 6 months? d. Often adolescents your age have questions about sexual activity.

d. Often adolescents your age have questions about sexual activity. The interview should begin with a permission statement, which conveys that it is normal and acceptable to think or feel a certain way. Sounding judgmental should be avoided.

A 25-year-old woman comes to the emergency department with a sudden fever of 38.3 C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: a. Endometriosis. b. Uterine fibroids. c. Ectopic pregnancy. d. Pelvic inflammatory disease.

d. Pelvic inflammatory disease. These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis (see Table 26-7). (For the descriptions of endometriosis and uterine fibroids, see Table 26-6; for a description of ectopic pregnancy, see Table 26-7.)

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

d. Positive Romberg sign. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis

When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurses most appropriate action or response is to: a. Ask the patient if he would like someone else to examine him. b. Continue with the examination as though nothing has happened. c. Stop the examination, leave the room while stating that the examination will resume at a later time. d. Reassure the patient that this is a normal response and continue with the examination.

d. Reassure the patient that this is a normal response and continue with the examination. When the male patient has an erection, the nurse should reassure the patient that this is a normal physiologic response to touch and proceed with the rest of the examination. The other responses are not correct and may be perceived as judgmental.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

d. Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)

Which statement concerning the testes is true? a. The lymphatic vessels of the testes drain into the abdominal lymph nodes. b. The vas deferens is located along the inferior portion of each testis. c. The right testis is lower than the left because the right spermatic cord is longer. d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body. When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes closer to the body to absorb heat necessary for sperm viability. The lymphatic vessels of the testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis. The left testis is lower than the right because the left spermatic cord is longer.

A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. Which statement does the nurse know to be true regarding this visit? a. Her cervical mucosa will be red and dry looking. b. She will not need to have a Pap smear performed. c. The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. d. The nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination.

d. The nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination. In the aging adult woman, natural lubrication is decreased; therefore, to avoid a painful examination, the nurse should take care to lubricate the instruments and the examining hand adequately. Menopause, with the resulting decrease in estrogen production, shows numerous physical changes. The cervix shrinks and looks pale and glistening. With the bimanual examination, the uterus feels smaller and firmer and the ovaries are not normally palpable. Women should continue cervical cancer screening up to age 65 years if they have an intact cervix and are in good health. Women who have had a total hysterectomy do not need cervical cancer screening if they have 3 consecutive negative Pap tests or 2 or more consecutive negative HIV and Pap tests within the last 10 years.

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers. A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.

During a health history, a 22-year old woman asks, Can I get that vaccine for human papilloma virus (HPV)? I have genital warts and Id like them to go away! What is the nurses best response? a. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today. b. This vaccine is only for girls who have not yet started to become sexually active. c. Lets check with the physician to see if you are a candidate for this vaccine. d. The vaccine cannot protect you if you already have an HPV infection.

d. The vaccine cannot protect you if you already have an HPV infection.

A 70-year-old woman tells the nurse that every time she gets up in the morning or after shes been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be: a. Have you been extremely tired lately? b. You probably just need to drink more liquids. c. Ill refer you for a complete neurologic examination. d. You need to get up slowly when youve been lying down or sitting.

d. You need to get up slowly when youve been lying down or sitting. Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

Orchitis is (are): a. a meatus opening on the dorsal side of the glans or shaft. b. hard, subcutaneous plaques associated with painful bending of the erect penis. c. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. d. an acute inflammation of the testes.

d. an acute inflammation of the testes. Orchitis is an acute inflammation of the testes. Epispadias is a meatus opening on the dorsal side of the glans or shaft. Peyronie disease is a result of hard, nontender, subcutaneous plaques on the penis that cause a painful bending of the penis during an erection. A hydrocele is a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

The first sign of puberty in girls is: a. the first menstrual cycle (menarche). b. axillary hair development. c. rapid increase in height. d. breast and pubic hair development.

d. breast and pubic hair development. The first signs of puberty are breast and pubic hair development, beginning between 8½ and 13 years of age. These signs usually occur together, but it is not abnormal if they do not develop together. This development takes about 3 years to complete. Menarche occurs during the latter half of the sequence of breast and pubic hair development, just after the peak of growth velocity. Coarse curly hairs develop in the pubic area first and then in the axillae.