Med Surg 2.2
In order to ensure a quality specimen and an accurate test result, which instruction should the nurse give a client who is scheduled to undergo urine endocrine testing? "Start the urine collection when the bladder is full." "Store the urine specimen in a cooler with ice." "Store the urine specimen in a home refrigerator." "Save the urine specimen that begins the collection."
"Store the urine specimen in a cooler with ice." The urine specimen that is collected for endocrine testing should be stored in a cooler with ice to prevent bacterial growth in the specimen. The nurse should instruct the client to start the urine collection after emptying the bladder. The client should be instructed not to store the urine specimen in a home refrigerator with other food and drinks as it could lead to cross-contamination. The client should be instructed to refrain from saving the urine specimen that begins the collection because the timing for urine collection starts from after the initial voiding specimen.
A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase? "The client will adhere to the teaching plan." "The client will achieve psychologic adjustment." "The client will maintain present muscle strength."
"The client will maintain present muscle strength." The client will prepare for a possible myasthenic crisis." Until the diagnosis has been confirmed, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis has not yet been established. The response "achieve psychologic adjustment" is too early; the client cannot adjust if a diagnosis has not yet been confirmed. The response "prepare for a possible myasthenic crisis" is an intervention, not an objective. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
What is acromegaly ?
Acromegaly is caused by hyperpituitarism. Symptoms include thickened lips, coarse facial features, and lower-jaw protrusion. Abnormal protrusion of the eyes is seen in clients with exophthalmos. Addison's disease, also called Addison's insufficiency, causes skin manifestations, such as vitiligo and hyperpigmentation. A client with Cushing's disease displays "moon face" and truncal obesity.
What a stage two pressure ulcer looks like What battle sign looks like
A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling. The condition depicted in the figure is Battle's sign, which is characterized by postauricular ecchymosis. Otorrhea is the leakage of cerebrospinal fluid from the ear. A halo sign indicates the presence of blood in the cerebrospinal fluid. Rhinorrhea is the leakage of cerebrospinal fluid from the nose. Test-Taking Tip: Some clinical manifestations are also seen after several hours of fractures, which may be due to cranial nerve defects. Observe clearly for the indication in the figure to choose a correct answer option.
A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. Which is a priority nursing action? Tell the client that chest tubes will be present after the procedure. Explain that the procedure will allow visualization of lungs and chest cavity. Inform the client that some pleural fluid will be removed during this procedure. Advise the client to avoid eating or drinking anything for several hours before the test.
Advise the client to avoid eating or drinking anything for several hours before the test. To prevent aspiration during the procedure, clients are required to be nothing by mouth before the procedure. Chest tubes are not required unless the lungs are punctured accidentally. A mediastinoscopy permits visualization of the anterior mediastinum or hilum extrapleurally; bronchoscopy permits visualization of the larynx, trachea, and bronchi. Fluid is removed from the pleural space during a thoracentesis.
Which hormonal deficiency reduces the growth of axillae and pubic hair in female clients? Growth hormone Antidiuretic hormone Thyroid-stimulating hormone Adrenocorticotropic hormone
An adrenocorticotropic hormone deficiency causes a reduced growth of axial and pubic hair in women. A growth hormone deficiency causes decreased muscle strength and decreased bone density. An antidiuretic hormone deficiency causes excessive urine output and a low urine specific gravity. A thyroid-stimulating hormone deficiency results in hirsutism and menstrual abnormalities.
The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse? Tell the spouse to let the client do things independently. Allow the spouse to assume total responsibility for the client's care. Explain that the nursing staff has full responsibility for the client's activities. Ask the spouse for assistance in planning those activities most helpful to the client.
Ask the spouse for assistance in planning those activities most helpful to the client. To foster communication and cooperation, family members should be involved in planning and implementing care. Telling the spouse to let the client do things independently does not focus on feelings or needs. The spouse may promote dependency in the client to satisfy a need to control. Although the nursing staff does have full responsibility for the client's activities, the family should be involved. Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate.
Which description could be related to zosteriform-type lesions? Wide distribution Diffuse distribution Bilateral distribution Band-like distribution
Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.
Which catecholamine receptor is responsible for increased heart rate? Beta1 receptor Beta2 receptor Alpha1 receptor Alpha2 receptor
Beta1 receptors are responsible for increased heart rate. Beta2 receptors, alpha1 receptors, and alpha2 receptors are not present in the heart; therefore, they are not responsible for increasing the heart rate. Beta2 receptors are present in such organs as blood vessels, kidneys, bronchioles, and bladder. Alpha receptors are present in such organs as eyes, skin, and liver.
9. How is the brachioradialis reflex elicited? By striking the triceps tendon above the elbow By striking the radius 3 to 5 cm above the wrist By striking the patellar tendon just below the patella By striking the Achilles tendon when the client's leg is flexed
By striking the radius 3 to 5 cm above the wrist The brachioradialis reflex can be elicited by striking the radius 3 to 5 cm above the wrist while the client's arm is relaxed. Striking the triceps tendon above the elbow elicits the triceps reflex. Striking the patellar tendon just below the patella elicits the patellar reflex. Striking the Achilles tendon elicits the Achilles tendon reflex when the client's leg is flexed.
Which structure lies inside and parallel to the sclera? Lens Choroid Conjunctiva Ciliary processes
Choroid The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina. It lies parallel to the sclera. The lens is located behind the iris. The conjunctiva covers the inner surfaces of the eyelids and also extends over the sclera. The ciliary processes lie behind the peripheral part of the iris.
The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? Emotional lability is associated with brain trauma. Their presence allows the client to express feelings. The client is depressed about the loss of functional abilities. Nonverbal expressions of feelings are more accurate than verbal ones.
Emotional lability is associated with brain trauma. Emotional lability is associated with brain trauma from ischemia or injury. The frontal lobe, hypothalamus, thalamus, and cortical limbic system are involved in expression of emotions. Emotional lability is not limited to interactions with family. Although the client may be depressed, the uncontrollable tearfulness is because of the disease process. Although nonverbal messages are often helpful in determining emotional response, these emotional outbursts may be unrelated to feelings.
Which client has a primary lesion? One with scales One with ulcers One with fissures One with erosions
Erosions are considered primary lesions. Scales, ulcers, and fissures are secondary lesions, which are modifications of primary lesions
Which characteristic does the nurse associate with a punch biopsy? It is usually indicated for superficial or raised lesions. It is more uncomfortable than other biopsies while healing. It is performed using a circular cutting instrument 2 to 6 mm in diameter. It removes only the portion of the skin that rises above the surrounding tissue.
It is performed using a circular cutting instrument 2 to 6 mm in diameter. punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.
Which practice would be suitable in the prevention of a pressure ulcer? Positioning a client directly on the trochanter Keeping the client's skin directly off plastic surfaces Keeping the head of the bed elevated above 30 degrees keep applying lotion all day
Keeping the client's skin directly off plastic surfaces Placing a rubber ring or donut under the client's sacral area For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.
Which muscle helps in moving the eye diagonally downward towards the middle of the head? Select all that apply. Lateral rectus muscle Medial rectus muscle Inferior rectus muscle Inferior oblique muscle Superior oblique muscle
Medial rectus muscle Inferior rectus muscle The inferior rectus muscle together with the medial rectus moves the eye diagonally downward towards the middle of the head. The lateral rectus muscle together with the medial rectus muscle holds the eye straight. The medial rectus muscle helps in turning the eye towards the nose. The inferior oblique muscle will pull the eye upward. The superior oblique muscle pulls the eye downward.
8. Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis? Monitoring urinary output Assessing nutritional status Monitoring respiratory status Assessing communication needs
Monitoring respiratory status The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning, or if the client is intubated, verbal communication abilities are lost.
Which dermatologic problem is treated by using intralesional corticosteroids? Psoriasis Cellulitis Erysipelas Carbuncles
Psoriasis is a dermatologic problem treated by using intralesional corticosteroids. Cellulitis, erysipelas, and carbuncles are treated by using systemic antibiotics such as synthetic sulfur.
. A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare? Enzymatic agents Scissors and forceps Autolytic semi-occlusive dressing Continuous passive-motion device
Scissors and forceps Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.
A debilitated older client with glaucoma who places great value on independence is being prepared for discharge from the hospital. To promote independence, what should the nurse encourage the client to do? Prevent stressful events that can increase symptoms Conserve eyesight by not reading or watching television Perform household chores and shopping without assistance Self-administer the eye medications using appropriate technique
Self-administer the eye medications using appropriate technique The responsibility for correctly doing this task will foster independence. Preventing stressful events that increase symptoms is a laudable goal, but it does not relate to independence. Moderate use of the eyes is not contraindicated in clients with glaucoma. Performing household chores and shopping is too ambitious for a debilitated older client.
Which does the nurse understand related to negative pressure wound therapy? Select all that apply. Using a suction pump Treating necrotizing infections Administering oxygen under high pressure Application of a low-voltage current to a wound area Reducing chronic ulcers by removing fluids from the wound
Suction pump Reducing chronic ulcers In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.
Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output? An expected effect of the dye used with the procedure Increased cardiac output as a result of the procedure An improvement of urinary functioning after the catheterization A physiologic effect of the prescribed intravenous (IV) rate of 50 mL/hr
an expected effect of the dye used with the procedure The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; it neither improves cardiac function nor increases cardiac output, and it does not improve urinary functioning. An IV rate of 50 mL/hr will not cause a urinary output three times the amount of intake.
A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? Moro Babinski Stepping Cremasteric
babinski This is the description of how to elicit the Babinski reflex. If it is present in adults it may indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns. It disappears between the third and fourth months; if present after four months, neurologic disease is suspected. The stepping reflex is expected in newborns. It disappears at about three to four weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.
Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin? Punch biopsy Shave biopsy Incisional biopsy Excisional biopsy
excisional biopsy An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.
A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake? Increased amounts of potassium are needed to replace renal losses. Increased protein is needed to heal the adrenal tissue and thus cure the disease. Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. Extra salt needed
extra salt Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium. Lack of mineralocorticoids (aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing; nor will they help the client gain weight.
What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. Prolactin Growth hormone Luteinizing hormone Antidiuretic hormone Melanocyte-stimulating hormone
growth hormone and prolactin he most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.
A nurse teaches a client who has had a thyroidectomy for thyroid cancer to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? Select all that apply. Dry skin Lethargy Insomnia Tachycardia Sensitivity to cold
lethargy sensitivity to cold dry skin Dry skin is a response to hypothyroidism that is related to the associated decreased metabolic rate. Lethargy and sensitivity to cold are symptoms related to hypothyroidism that are associated with a decreased metabolic rate. Insomnia and tachycardia are related to hyperthyroidism, not hypothyroidism.
Which organism infestation is diagnosed with the help of the mineral oil test? Lice Ticks Mites Fungus
mites Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically. Lice leave excrement and eggs on skin and hair, live in seams of clothing (if body lice), and in hair as nits. A diagnosis of Lyme disease caused by ticks is often based on clinical manifestations, in particular the erythema migrans lesion, and a history of exposure in an endemic area. If the enzyme immunoassays is positive or inconclusive, a Western blot test is done to confirm the infection. The microscopic examination of skin lesions in 10% to 20% potassium hydroxide is a diagnostic measure to determine the presence of a fungus.
After assessing a client's vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition does the nurse suspect the client is experiencing? Myopia Hyperopia Presbyopia Astigmatism
myopia client with myopia may not be able to see objects which are far away. Hyperopia is the inability to visually accommodate near objects. Presbyopia is loss of accommodation associated with age. Astigmatism is an irregular corneal curvature. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
Which procedure is preferred to find out the composition of a thyroid nodule and ascertain the need for further surgical intervention in a client? Mass spectrometry Computed tomography scans Glycosylated hemoglobin test Needle biopsy
needle biopsy Needle biopsy is an ambulatory surgical procedure. A fine needle is used to aspirate the contents of thyroid nodules to study the composition and ascertain the need for further surgical interventions. Mass spectrometry is an assay in which several different hormone concentrations can be simultaneously analyzed. Computed tomography scans are useful for evaluation of ovaries, adrenal glands, and the pancreas. The average blood glucose level over 2 to 3 months is revealed by a glycosylated hemoglobin test.
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? T-tube movement increases. Pain at the incision site increases. The nasogastric tube gets irritating. The bandage on the abdomen is constricting.
pain at the incision site increases incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.