med surg EAQs

A client has chronic asthma. Which complication should the nurse monitor in this client?

Atelectasis

Postoperatively, a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect the client is experiencing?

Hypocalcemia

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

Paroxysmal hypertension and bradycardia

While a client with a fractured femur is being prepared for surgery, the client exhibits cyanosis, tachycardia, dyspnea, and restlessness. What should be the nurse's first action?

The client probably has a fat embolus; oxygen reduces surface tension of the fat globules and reduces hypoxia. Oxygen should be administered before the healthcare provider is called.

Which response should a nurse expect a client diagnosed with cerebellum dysfunction to exhibit?

Uncoordinated movements

The nurse is caring for a client who is diagnosed with diabetes insipidus and is on intranasal desmopressin acetate (DDAVP). The client develops an upper respiratory tract infection during a hospital stay. Which alteration does the nurse anticipate in the client's prescription?

the best alternative is to administer the DDAVP via oral or subcutaneous routes. The subcutaneous (parenteral) form of DDAVP is almost 10 times more potent than intranasal and oral forms. Therefore, if opting for subcutaneous route, the dose of DDAVP should be reduced.

A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary?

"The fingertip is preferred for glucose monitoring if hyperglycemia is suspected." The fingertip is preferred for glucose monitoring if hypoglycemia, not hyperglycemia, is suspected.

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid, and the serum electrolyte value demonstrates hyponatremia. What would the nurse concludes was the element that most likely contributed to the hyponatremia?

*Fluid intake* Hemodilution has occurred because the 1500 mL of intravenous fluid has lowered the serum sodium level.

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have?

*Obstructive sleep apnea* (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea.

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit?

*Pallor* occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. *Heart rate accelerates* in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. *Urinary output decreases* with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. *Respirations increase* and become shallow with hemorrhage as the body attempts to take in more oxygen. *Hypotension* occurs in response to hemorrhage as the person experiences hypovolemia.

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history?

*Streptococcal infections occurring in childhood* may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart.

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults.

Contractures and burns

A client whose lateral trunk is affected due to burns should be placed in supine position with the affected arm over the head to reduce the risk of contractures. A client whose wrist is affected should use a splint. The nurse should maintain the upper arm at 90 degrees of abduction from the lateral aspect of the trunk of a client whose anterior shoulder is affected. The nurse should keep the arm slightly behind the midline of a client whose posterior shoulder is affected.

The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client?

A client with cataracts has increased lens density due to drying and compression of older lens fibers. Clients with disease conditions such as diabetes mellitus may develop cataracts. Therefore the client's blood glucose levels should be assessed to determine the severity of the disease. Surgery is the only "cure" for cataracts. Before performing surgery, the client should be assessed for any conditions that may affect blood clotting, such as use of aspirin and clopidogrel.

Which medication should the nurse anticipate being prescribed for a client with C. difficile-associated disease (CDAD)?

A new oral antibacterial drug available specifically for managing C. difficile is fidaxomicin. Oral metronidazole and vancomycin have been the drugs of choice to treat CDAD.

What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy?

A stomal cover or scarf allows air to move into and out of the trachea but prevents particles of dirt and insects from entering the stoma.

A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider?

A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and could indicate hypertension.

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery?

After a thyroidectomy, it is critical to monitor for stridor, dyspnea, or other symptoms of acute airway obstruction that may result postoperatively. It is important to inspect the neck dressing, as well as the sides of the neck and behind the neck, for blood that may drain in that direction by gravity. The client needs to be placed in a semi-Fowler position to decrease tension on the suture line. Vital signs need to be monitored every 15 minutes until the client is stable, then every 30 minutes for 24 hours. Although this may be a complication of this surgery, tetany will not occur during the first 4 hours after surgery.

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged?

Anterior cerebral

A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are as follows: pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq (25 mmol/L). The nurse should take which action?

Ask the client to cough forcefully and take deep breaths. The client is in respiratory acidosis probably caused by the depressant effects of anesthesia or a partially obstructed airway; these activities clear the airway and blow off CO2.

The X-ray report of a client indicates a reduction in the alveolar surface area. Which condition can be inferred from this finding?

Atelectasis, a condition that involves alveolar collapse, may occur due to the absence of surfactants. This condition causes a reduction in the alveolar surface area, which in turn reduces the gas exchange.

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?

Avoid bending from the waist. Bending increases intraocular pressure and must be avoided.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected?

CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; thus the pupils will remain dilated even upon exposure to a light source.

A client with a head injury has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing. What should the nurse conclude from these clinical findings?

Cerebral compression affects pyramidal tracts, resulting in flexion (decorticate) rigidity and cranial nerve injury, which cause pupil dilation.

Which statements are true regarding chondrosarcoma?

Chondrosarcoma is a malignant type of bone tumor that can arise from benign bone tumors. Chrondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.

The nurse is caring for different clients in a healthcare setting who are diagnosed with respiratory disorders. Which client may have the anteroposterior chest diameter equal to the lateral chest and the slope of the ribs more horizontal to the spine?

Client with cystic fibrosis may have increased anteroposterior diameter; that is, the anteroposterior chest diameter is equal to the lateral chest measurement and the slope of the ribs are more horizontal to the spine.

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula?

Clients who receive many visitors while sitting in a chair are more mobile and will benefit from a less restrictive form of oxygen administration. The client will be able to talk without the impediment of a mask.

While interacting with a client, the nurse notices a lack of coordination in the client's speech. What could be the reason behind this condition?

Cranial nerve lesions can cause a lack of coordination in articulating speech, as the cranial nerves are responsible for speech coordination.

While assessing a client with acquired immunodeficiency syndrome, the nurse suspects that the client has developed cryptosporidiosis. Which symptoms support the nurse's suspicion?

Cryptosporidiosis is an intestinal infection caused by Cryptosporidium. The symptoms of cryptosporidiosis are diarrhea and weight loss.

Which drug is most appropriate for relieving a painful muscle spasm in the back of a client with osteoarthritis (OA)?

Cyclobenzaprine hydrochloride is a muscle relaxant administered to relieve painful muscle spasms, especially those resulting from OA of the vertebral column.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in *metabolic acidosis*. Hyperkalemia will occur because of renal shutdown. In late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.

A client feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. What causes increased fatigue with type 1 diabetes?

Decreased production of insulin by the pancreas Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue.

A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question?

Dialysate is introduced into the peritoneal cavity where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane.

A nurse is caring for a client who has a prescription for a 2-gram sodium diet and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) 42 mg/dL (15.2 mmol/L) and creatinine 1.1 mg/dL (97 mcmol/L). Considering the assessment findings, what is the most appropriate intervention by the nurse?

Diuretics cause dehydration, increasing the BUN; increasing fluid intake will result in a decrease in the BUN level.

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning?

Dullness can be percussed over an atelectatic lung or a consolidated lung. Tympanic notes over the lung usually indicate a large pneumothorax. Flatness percussed over the lung fields indicates massive pleural effusion.

The nurse is caring for a client after the client's open heart surgery (coronary artery bypass grafting [CABG]). Serosanguineous fluid drains from the client's chest tube. The nurse expects what volume of drainage from the tube during the first 24 hours after the surgery?

During the first 24 hours after CABG surgery, 500 mL of fluid will accumulate in the intrapleural space because of trauma and the inflammatory response; gradually, this amount will decrease.

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client?

Dyspnea during activities such as showering and dressing and the ability to walk for more than a city block, but only at their own pace without being able to keep up with others, indicates class III dyspnea.

A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings?

Expected course of pneumonia

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion?

FES is characterized by the presence of systemic fat globules, which are distributed into tissues and organs after a traumatic skeletal injury. The presence of fat cells in the urine indicates FES. Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis that produces signs and symptoms of acute respiratory distress syndrome (ARDS) and decreased partial pressure of arterial oxygen. The normal partial pressure of arterial oxygen is 80 to 100 mm Hg (10.6-13.33 kPa). The normal hematocrit value is 40% to 50% (0.40-0.50). Poor oxygen exchange decreases the hematocrit value in a client with FES.

A client complains of fatigue, hair loss, and weight gain. On assessment, the client is found to have anemia. Which therapy does the nurse anticipate in the client's prescription?

Fatigue, hair loss, weight gain, and anemia are the clinical manifestations of hypothyroidism, which occurs due to deficiency of thyroid hormones. Treatment includes restoration of euthyroid state by hormone therapy, such as levothyroxine.

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include?

Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema.

A nurse is preparing to assess the client's thyroid gland. Arrange the procedure for posterior palpation of the thyroid gland in sequence.

First stand behind the client and place the thumbs on the nape of the client's neck. Then use the index and middle fingers to feel the thyroid isthmus. Ask the client to flex the neck slightly forward and to the right to relax the neck muscles. Next palpate the sternocleidomastoid muscle with the index and middle fingers of the right hand. The thyroid will move up when the nurse asks the client to swallow water.

A client with an aldosterone-secreting adenoma is scheduled for surgery to remove the tumor. The client asks what will happen if surgery is canceled. On what fact does the nurse base her response?

Heart and kidney damage may occur if the tumor is not removed. Renal and cardiac complications will occur if hypertension is not arrested.

Which assessment finding is characteristic of a client with hypoparathyroidism?

Hypoparathyroidism is manifested by increased serum phosphorus and decreased serum magnesium concentration. The normal level of serum phosphorus ranges from 3 to 4.5 mg/dL (0.97-1.45 mmol/L) and the normal serum magnesium level ranges from 1.3 to 2.1 mEq/L (1.3-2.1 mmol/L).

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected?

Impaired ability to state wishes verbally is a characteristic of expressive aphasia from damage to Broca area in the dominant hemisphere of the brain.

A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)?

In ECG tracing, the displacement of the S-T segment is caused by an active ischemic injury in the myocardium.

After recording the blood pressure of a client, the primary health care provider confirms a diagnosis of pheochromocytoma. What blood pressure may have helped confirm the diagnosis?

Increased blood pressure indicates the presence of pheochromocytoma. The increase in blood pressure could be due to the increased production of catecholamines, indicating endocrine imbalance.

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition?

Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia.

Which statements indicate a nurse has a correct understanding of interleukin-2?

Interleukin-2 is used clinically to enhance natural killer cells, treat various malignancies, and stimulate differentiation of T-lymphocytes. Interleukin-1 is used as an anti-inflammatory agent.

A client with tuberculosis is prescribed isoniazid. What statements should the nurse tell the client?

Isoniazid should be taken on an empty stomach because food prevents absorption of the drug. Multiple vitamins that contain the vitamin B-complex should be taken along with isoniazid because the drug depletes vitamin B. A client on isoniazid should report darkening of the urine and yellowish skin discoloration because these conditions are signs of liver toxicity.

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

Lesions that affect the seventh cranial (facial) nerve cause paralysis of eyelids; it controls the eye blink.

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods?

Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are also high-purine foods and should be avoided.

The nurse is caring for a client who just had a posterior lumbar laminectomy. Which action is the priority?

Log-rolling maintains the alignment of the vertebral column by turning as a unit.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation.

A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition?

Methylprednisolone is a corticosteroid that suppresses inflammatory responses and inhibits both cytokine production and T-cell activation.

A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site for changes in temperature and color should indicate the presence or absence of a clot; comparing pedal pulses of both extremities may reveal clot formation that disrupts circulation.

A client who had a subtotal thyroidectomy returns to the unit from the postanesthesia care unit. What is the priority nursing action at this time?

Observe for signs of tetany. The parathyroids may be excised accidentally during surgery; because they regulate calcium, lowered blood levels of calcium may induce tetany.

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation?

Older adults are at an increased risk for complications from both anesthesia and surgery. One of the age-related risk factors after surgery is a decrease in vital capacity. Teaching coughing and deep-breathing exercises may help in preventing pulmonary complications.

The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema?

Palpate around the tube insertion sites for crepitus. Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated.

A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. What should the nurse teach the client to do to use the walker?

Place the walker flat on the floor with the front legs about 12 inches (30.5 cm) in front of the feet, shift the body weight to the walker, and step forward to take initial steps.

The nurse is caring for a client who underwent a contrast-based cerebral angiography. Which nursing interventions will be beneficial after the procedure?

Providing oral or intravenous fluids after a contrast-based cerebral angiography aids in the excretion of the contrast agent. A pressure dressing at the injection site helps to prevent bleeding. The kidney function should be evaluated 24 hours after the test because the contrast agent may cause kidney damage.

A female client has thick, reddened papules covered by silvery white scales on the knees. The borders between the lesions and normal skin are sharply defined. The primary healthcare provider prescribes a drug and advises her to strictly adhere to the contraceptive measures. Which drug might have been prescribed?

Psoriasis vulgaris is an autoimmune disorder that affects the skin with exacerbations and remissions. It causes thick, reddened papules covered by silvery white scales. Acitretin may be used for treatment. This is a teratogenic drug; therefore the client must strictly adhere to the strict contraceptive measures and not get pregnant.

A nurse caring for a client with quadriplegia notices ulcers on the sacrum, hips, and ankles. Arrange the order of the pathophysiology involved in the development of these ulcers.

Quadriplegic clients are bedridden or wheelchair bound and incapable of changing position without assistance; therefore they have more chances of developing pressure ulcers. Tissue compression from pressure restricts blood flow to the skin resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death and the development of pressure ulcers.

A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. Which consideration is priority when the nurse is planning room placement?

Radon seeds emit radiation; the client should be isolated in a private room to decrease radiation to others.

Which medications act by binding with integrase enzyme and prevent human immunodeficiency virus (HIV) from incorporating its genetic material into the client's cell?

Raltegravir and elvitegravir

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first?

Record the temperature reading and continue to monitor it. Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days.

What should the nurse expect when assessing a client with pleural effusion?

Reduced or absent breath sounds at the base of the lung

A nurse is assessing a client admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?

Retention of sodium and water

The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis?

SIADH is manifested in the form of retention of free water. This is because of excessive secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia and dilution of serum sodium in SIADH.

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip?

Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout, with the exception of the dropped beat(s).

To reduce a fracture of the hip, a client is placed in Buck traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction?

Slight trendelenburg position: Elevating the foot of the bed uses gravity and the client's weight for countertraction.

Acromegaly

Somatotropin values should be less than 4 ng/mL (4 mcg/L) in males and less than 18 ng/mL (18 mcg/L) in females. Somatotropin values greater than 50 ng/mL indicate acromegaly. Somatomedin C levels greater than 449 ng/mL indicate excess growth hormone levels, which indicate acromegaly.

A nurse witnesses a client collapse during a home care visit. Place the basic life support actions in the order they should be performed by the nurse.

Stimulation is required to determine if the person is actually unresponsive. Immediate activation of the emergency management system shortens response time and decreases mortality rate. Observing the rise of the chest and listening and feeling for the presence of breathing will determine if further action is needed. Palpation of the pulse determines if cardiac compression is needed. Begin 30 chest compressions to a depth of 2 inches (5 cm); this compresses the heart and pushes blood into the circulation. Opening the airway results in spontaneous breathing or prepares the person for two rescue breaths if needed. If two rescue breaths are given, they are alternated with chest compressions; rate is 30 compressions to two rescue breaths for a single rescuer, and 15 compressions to two rescue breaths for two rescuers.

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, which should the nurse evaluate?

The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea.

A client's blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse identify when monitoring this client's laboratory values?

The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids; in metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids. The pH is decreased.

A client is on tobramycin therapy. Which assessment findings should be given priority?

The client may suffer blurred vision, hearing impairment, or decreased sense of smell as side effects associated with tobramycin. These findings should be given high priority, and measures to reverse the toxicity should be taken so as to prevent permanent damage. Excessive use of tobramycin is associated with side effects that include nephrotoxicity, neurotoxicity, and hearing deficit.

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next?

The client's response indicates lack of physiologic tolerance to the procedure, and it must be interrupted.

During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. Which medical diagnosis will the nurse most likely observe documented in the client's electronic records?

The data presented indicate an infectious process within the lung. The classic clinical findings associated with pneumonia are a productive cough (sputum is purulent, blood-tinged, or rust-colored), fever, chills, pleuritic chest discomfort, and dyspnea. Percussion is dulled over areas of consolidation.

Which order of actions should a nurse follow when performing a chest examination of a client with a pulmonary disorder?

The first step is to observe the client`s appearance and note any evidence of respiratory distress. Next, the shape and symmetry of the chest along with the chest movements should be determined. After this step, the nurse should check for any abnormalities of the sternum such as pectus carinatum and pectus excavatum. Finally, the nurse should observe for any respiratory rates and abnormal breathing patterns such as Kussmaul breathing or Cheyne-Stokes respiration.

How should the nurse arrange the order of steps in normal wound healing in the proliferative phase?

The normal wound healing in the proliferative phase begins on the fourth day after injury and lasts 2 to 4 weeks as the fibrin strands form a scaffold or frameworks and mitotic fibroblast cells migrate into the wound after the formation of the framework. Then collagen builds tough and inflexible scar tissue. Capillaries surrounding the wound form "buds" that grow into new blood vessels. These buds and a collagen deposit from the granulation tissue in the wound help the wound contract and fill, and epithelial cells grow over the granulation tissue bed.

While assessing a postpartum client who is suspected of having a thyroid disorder, the nurse suspects that the client has autoimmune thyroiditis. Which diagnostic studies are most suitable for confirming the diagnosis?

The postpartum client may have silent, painless thyroiditis. Radioactive iodine uptake is suppressed in silent thyroiditis, so this test would be beneficial in diagnosing the thyroiditis.

During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign?

The short, discontinuous, high-pitched sounds that sound like hair being rolled between fingers just behind the ear in the bilateral lower lobes indicate fine crackles. These sounds may be auscultated in clients with pulmonary disorders such as idiopathic pulmonary fibrosis, atelectasis, and pulmonary edema.

While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in which position?

The side-lying position will neither raise intracranial pressure nor interfere with respirations and will permit oral secretions to drain from the mouth by gravity.

An 11-year-old client is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for which therapies?

The symptoms indicate possible Hodgkin lymphoma, so diagnostic testing will likely include CT and a lymph node biopsy.

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions?

The tidal volume is the amount of air inhaled and exhaled while breathing normally.

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action?

The wound must be covered to prevent atmospheric air from entering the pleural cavity until closed chest drainage can be instituted.

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip?

Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. The nurse should instruct the client to place weight on which part of the body?

To prevent nerve damage in the axillary area, the palms should bear all the weight.

A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder?

Ulceration of the intestinal mucosa commonly occurs, causing blood loss and anemia. The inflammatory process tends to increase peristalsis, causing diarrhea, electrolyte imbalances, and weight loss.

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do?

Use a soft toothbrush. The gums are vascular tissue and prone to bleed easily if the platelet count is low. Read the ingredients in over-the-counter drugs before taking them. Drugs such as ibuprofen and salicylates in any analgesic or cold medicine should be avoided because they increase the risk of bleeding by inhibiting platelet function.

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment?

Ventilatory exchange

A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit?

Weakness occurs in response to the excessive catabolism of proteins and resulting loss of muscle mass. Hypertension occurs in response to excessive cortisol that causes an increase in circulating volume or an arteriole response to circulating catecholamines. Truncal obesity is caused by abnormal fat metabolism and deposition of fat in the mesenteric bed.

What clinical indicators should a nurse assess when caring for a client with hyperthyroidism?

Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema.

A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider?

When the kidney senses a decreased circulating blood volume, angiotensin I is released, which produces angiotensin II, a powerful vasoconstrictor; also, it stimulates the adrenal cortex to release aldosterone, which causes active reabsorption of sodium and water. Baroreceptors in the aortic arch and carotid sinus respond to altered arterial pressure, initiating events that ultimately stimulate peripheral vasoconstriction, thus increasing cardiac output. Alpha1-adrenergic receptors are located in vascular smooth muscles and, when stimulated, cause vasoconstriction of the blood vessels.

A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report?

decreased peripheral vision

Which clinical manifestations in a client indicate hyperfunctional thyroid gland?

diarrhea and weight loss

A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture?

plain x-ray