N330 Summer 2024 Final Exam Review Questions

The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse (RN)? A. "Palliative care is the same as hospice care." B. "Palliative care focuses on the care of the client." C. "Palliative care includes symptom management in the client." D. "Palliative care is an interprofessional approach to the delivery of care."

"Palliative care is the same as hospice care." Rationale: The student nurse should not confuse palliative care with hospice care. Palliative care can be provided to any client at the time of diagnosis of a serious disease, whereas hospice care is provided to clients only at the very end of life. Palliative care is focused mainly on client care and symptom management to improve the quality of life. The entire health care team is involved in delivering palliative care to the client.

Which education would the nurse provide the parent of preschool child with atopic dermatitis? A. "Scratching causes lesions to become more contagious." B. "Scratching spreads dermatitis to other areas of the body." C. "Scratching results in skin breaks that can lead to infection." D. "Scratching produces changes that are precursors to skin cancer."

"Scratching results in skin breaks that can lead to infection." Rationale: Scratching can compromise the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching or dermatitis is a precursor to skin cancer.

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? Select all that apply. One, some, or all responses may be correct. A. Pain history, including location, intensity, and quality of pain B. Client's purposeful body movement in arranging the papers on the bedside table. C. Pain pattern, including precipitating and alleviating factors D. Vital signs, such as increased blood pressure and heart rate E. The client's family statement about increases in pain with ambulation

1 Pain history, including location, intensity, and quality of pain 2. Pain pattern, including precipitating and alleviating factors Rationale: The initial pain assessment should include information about the location, quality, intensity, onset, duration, and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a secondary assessment related to the initial pain assessment. Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality, and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the precipitating factors helps the nurse prevent the pain and determine its cause. Elevated blood pressure and heart rate are physiological responses to pain and not a direct evaluation of pain. Pain is a subjective experience, and the nurse has to ask the client directly instead of accepting the statement of the family members.

Which client would experience impaired near vision? Select all that apply. One, some, or all responses may be correct. A. A client with myopia B. A client with presbyopia C. A client with hyperopia D. A client with retinopathy E. A client with macular degeneration

1. A client with presbyopia 2. A client with hyperopia Rationale: A loss of elasticity of the lens causes impaired near vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.

When taking the history for a client who is being treated for obstructive sleep apnea, which findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. A. Daytime hypoxemia B. Chronic fatigue C. Enlarged tonsils D. Subcutaneous emphysema E. Poor concentration

1. Chronic fatigue 2. Enlarged tonsils 3. Poor concentration Rationale: Because obstructive sleep apnea (OSA) leads to poor sleep quality, clients typically report feeling tired all the time and having poor concentration. Enlarged tonsils obstruct the airway and lead to OSA. Although the client is hypoxemic during apneic spells when sleeping, oxygen levels are normal when the client is awake. Subcutaneous emphysema may occur with laryngeal trauma, but is not seen with OSA.

Which finding in the older adult client is associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct. A. Dysuria B. Urgency C. Confusion D. Incontinence E. Slight rise in temperature

1. Confusion 2 Incontinence 3. Slight rise in temperature Rationale: An older adult client with a urinary tract infection (UTI) is likely to appear confused and may experience incontinence, whereas a younger client is cognitively intact and typically experiences urgency. The older adult client may develop only a slight rise in temperature, whereas the hallmark symptoms of a UTI in a younger client are fever, dysuria, and urgency.

Which manifestation would the nurse include when teaching a client about ketoacidosis? Select all that apply. One, some, or all responses may be correct. A. Confusion B. Hyperactivity C. Excessive thirst D. Fruity-scented breath E. Decreased urinary output

1. Confusion 2. Excessive thirst 3. Fruity-scented breath Rationale: Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include confusion, excessive thirst, fruity-scented breath, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, and shortness of breath. Weakness or fatigue, not hyperactivity, is a symptom. Frequent urination, not decreased urination, is a symptom.

Which expected sensory loss associated with aging would a nurse recall when designing a plan of care for an 85-year-old client admitted to a nursing home? Select all that apply. One, some, or all responses may be correct. A. Difficulty in swallowing B. Diminished sensation of pain C. Heightened response to stimuli D. Impaired hearing of high frequency sounds E. Increased ability to tolerate environmental hear

1. Diminished sensation of pain 2. Impaired hearing of high frequency sounds Rationale: Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age, they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

Which symptoms would the nurse observe in a client with hyperglycemia and ketoacidosis? Select all that apply. One, some, or all responses may be correct. A. Irritability B. Dry skin C. Diaphoresis D. Increased thirst E. Deep, rapid breathing

1. Dry skin 2. Increased thirst 3. Deep, rapid breathing Rationale: Hyperglycemia acts as an osmotic diuretic, resulting in increased urine output (polyuria) and dehydration. Dry skin is a sign of hyperglycemia resulting from dehydration. Thirst is a compensatory mechanism that causes a person to drink increased amounts of fluid (polydipsia). Deep, rapid breathing (Kussmaul breathing) is the body's effort to blow off carbon dioxide in an attempt to correct the metabolic acidosis associated with hyperglycemia and ketoacidosis. Irritability is an autonomic nervous system response to hypoglycemia, not hyperglycemia. Diaphoresis with pale, cool skin is an autonomic nervous system response associated with hypoglycemia, not hyperglycemia.

Which action would the nurse take to prevent venous thrombus formation in a postoperative client? Select all that apply. One, some, or all responses may be correct. A. Encourage an increase in oral fluid intake. B. Massage the client's extremities with lotion. C. Instruct the client to avoid crossing the legs. D. Remind the client to dorsiflex the feet frequently. E. Help the client use prescribed pneumatic sequential stockings. F. Plan discharge teaching about the need to avoid taking aspirin.

1. Encourage an increase in oral fluid intake. 2. Instruct the client to avoid crossing the legs. 3. Remind the client to dorsiflex the feet frequently. 4. Help the client use prescribed pneumatic sequential stockings. Rationale: Actions such as increasing fluid intake, avoiding crossing the legs, frequent dorsiflexion of the feet, and using pneumatic sequential stockings when in bed all help decrease venous thrombus risk. Massage of the legs is avoided because it can dislodge any developing venous thrombus and cause a pulmonary embolus. Because aspirin helps prevent venous thrombosis, it does not have to be avoided after discharge.

The nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications? Select all that apply. One, some, or all responses may be correct. A. Examine the feet daily. B. Wear well-fitting shoes. C. Perform regular exercise. D. Powder the feet after showering. E. Visit the primary health care provider weekly. F. Test bathwater with the toes before bathing.

1. Examine the feet daily. 2. Wear well-fitting shoes. 3. Perform regular exercise. Rationale: Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary health care provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.

Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")? Select all that apply. One, some, or all responses may be correct. A. Edema B. Polyuria C. Frequent voiding D. Suprapubic distention E. Continual incontinence

1. Frequent voiding 2. Suprapubic distention Rationale: With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and the client eliminated just enough urine to relieve the pressure and the urge to void. The cycle repeats as pressure again builds. Thus, frequent, small amounts are voided without emptying the bladder. As the client retains urine and the bladder enlarges, suprapubic distention occurs. Edema is a sign of fluid volume excess, not urinary retention. Polyuria, excessive amount of urine production, does not occur with urinary retention. Continual incontinence does not occur with urinary retention.

Which conditions can precipitate delirium? Select all that apply. One, some, or all responses may be correct. A. Infection B. Dementia C. Dehydration D. Urine retention E. Medications

1. Infection 2. Dehydration 3. Urine retention 4. Medications Rationale: Infections, especially urinary tract infections in older clients, may cause delirium because they may become systemic. A memory aid for recalling the causes of delirium is DELIRIUMS: Drugs, Emotional factors, Low arterial oxygen level, Infections, Retention of urine or feces, Ictal or postictal state, Undernutrition, Metabolic conditions, and Subdural hematoma. Dehydration and fluid and electrolyte imbalances may lead to delirium because of the decrease in fluid and change in concentrations of electrolytes in the brain. Retention of urine may progress to a urinary tract infection that becomes systemic, which can cause delirium. Dementia is a chronic, irreversible cause of mental status changes. It must be differentiated from delirium, which is treatable.

The nurse is advised to join a community health center that mainly caters to Latino clients. Which skill would the nurse develop to help reduce health disparities? Select all that apply. One, some, or all responses may be correct. A. Learning to speak basic medical Spanish B. Updating paper supplies at the health care facility C. Learning about the health literacy rate of the community D. Incorporating the health beliefs of the community in any nursing care plans E. Learning about and respecting unique beliefs and values prevalent among the group

1. Learning to speak basic medical Spanish 2. Learning about the health literacy rate of the community 3. Incorporating the health beliefs of the community in any nursing care plans 4. Learning about and respecting unique beliefs and values prevalent among the group Rationale: To provide effective health care service to the ethnic group, the nurse would learn to speak basic medical Spanish. This promotes communication and develops trust between the nurse and the clients. Learning about the clients' health literacy can help the nurse identify areas of opportunity for client education and health promotion. Incorporation of beliefs and values in plans of care can make the care more effective. The nurse would learn about the unique values and beliefs of the ethnic group and respect them to deliver equitable health care. Updating the paper supplies at the health care facility can be a responsibility of the nurse but will not help reduce health disparity.

Which complication of diabetes would the nurse assess for in a client with a long history of the disease? Select all that apply. One, some, or all responses may be correct. A. Leg ulcers B. Loss of visual acuity C. Increased creatinine clearance D. Prolonged capillary refill in the toes E. Decreased sensation in the lower extremities

1. Leg ulcers 2. Loss of visual acuity 3. Prolonged capillary refill in the toes 4. Decreased sensation in the lower extremities Rationale: Ulcers of the legs are a common response to the microvascular and macrovascular changes associated with diabetes. Retinopathy, damage to the microvascular system of the retina (e.g., edema, exudate, and local hemorrhage), occurs as a result of occlusion of the small vessels, causing microaneurysms in the capillary walls. Macrovascular changes in the distal capillary beds interfere with blood flow to the distal extremities. Decreased sensation in the lower extremities is a complication of diabetes. Consistent hyperglycemia causes a buildup of sorbitol and fructose in the nerves that leads to impairment via an unknown process. Creatinine clearance decreases, not increases, as renal function deteriorates in response to microvascular damage to the small blood vessels that supply the glomeruli.

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct. A. Lopsided smile B. Unilateral vision C. Incoherent speech D. Unable to raise right arm E. Symptoms started 2 hours ago

1. Lopsided smile 2. Unilateral vision 3. Incoherent speech 4. Unable to raise right arm 5. Symptoms started 2 hours ago Rationale: The signs of a stroke follow the acronym FAST. The F stands for facial drooping (a lopsided smile); A for arm weakness (inability to raise the right arm); and S for speech difficulties (incoherent speech) The T stands for time, as the signs and symptoms need to be evaluated as soon as possible. Tissue plasminogen activator (TPA) can be administered to reestablish blood flow if treatment is initiated within 4½ hours of stroke onset. Unilateral vision loss can also signify stroke.

Which is a normal finding during the regular checkup of an older adultl? Select all that apply. One, some, or all responses may be correct. A. Loss of turgor B. Urinary incontinence C. Decreased night vision D. Decreased mobility of ribs E. Increased sensitivity to odors

1. Loss of turgor 2. Decreased night vision 3. Decreased mobility of ribs Rationale: In older adults, the skin loses its turgor or elasticity, and there is fat loss in the extremities. Visual acuity declines with age; therefore decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A. Pregnancy B. Inactivity C. Aerobic exercise D. Tight clothing

Inactivity Rationale: A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

Which points will be part of the nurse preceptor's lecture on caring for the lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) older adult population? Select all that apply. One, some, or all responses may be correct. A. This group should be forced to answer any questions. B. May have sexual organs that conflict with their gender identity. C. Are at an elevated risk for disability from chronic disease and mental distress. D. Older adult clients are commonly heterosexual. E. May hide their gender identities and sexual orientations from the nurse and other health care providers.

1. May have sexual organs that conflict with their gender identity. 2. Are at an elevated risk for disability from chronic disease and mental distress. 3. May hide their gender identities and sexual orientations from the nurse and other health care providers. Rationale: Lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) older adult clients may face significant health disparities. Such clients may have sexual organs that conflict with their gender identities. Compared with heterosexual adults, LGBTQ+ older adults are at an elevated risk for disability from chronic disease and mental distress. LGBTQ+ older adult clients may try to hide their gender identities and sexual orientations from the nurse and other health care providers due to fear of rejection, discrimination, or lack of adequate health care. Like any client, LGBTQ+ clients would not be forced answer any questions with which they feel uncomfortable. Nurses would not assume an older adult client is heterosexual; as in any generation, some clients may identify as LGBTQ+.

Which responses would the nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply. One, some, or all responses may be correct. A. Nausea B. Palpitations C. Tachycardia D. Nervousness E. Warm, dry skin F. Increased respirations

1. Palpitations 2. Tachycardia 3. Nervousness Rationale: Palpitations are of neurogenic origin associated with hypoglycemia; the sympathetic nervous system is stimulated by the decline in blood glucose. Tachycardia occurs with low serum glucose levels because of sympathetic nervous system activity. Nervousness, anxiety, and shakiness occur as a result of sympathetic nervous system stimulation associated with hypoglycemia. Nausea, vomiting, and abdominal cramps are associated with hyperglycemia. Warm, dry skin is a sign of hyperglycemia, caused by dehydration associated with osmotic diuresis related to glycosuria. The skin will be cool and moist with hypoglycemia. Increased respirations are signs of hyperglycemia and diabetic ketoacidosis from insufficient insulin to prevent fat breakdown for energy. There is no change in respirations with hypoglycemia.

Which throat manifestations are the key features in a client with acute viral pharyngitis? Select all that apply. One, some, or all responses may be correct. A. Petechiae on the soft palate B. Scant or no tonsillar exudate C. Slight erythema of the pharynx and tonsils D. Severe hyperemia of the pharyngeal mucosa E. Erythema of the tonsils with yellow exudates

1. Scant or no tonsillar exudate 2. Slight erythema of the pharynx and tonsils Rationale: The throat manifestations of acute viral pharyngitis are scant or no tonsillar exudate and slight erythema of the pharynx and tonsils. Petechiae on the soft palate, severe hyperemia of the pharyngeal mucosa, and erythema of the tonsils with yellow exudates are the manifestations of acute bacterial pharyngitis.

The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. Which instruction would the nurse include in the teaching plan? Select all that apply. One, some, or all responses may be correct. A. The client should obtain a finger-stick blood glucose reading before each meal. B. The client does not need to follow a specific diet until insulin is required. C. The teaching plan should include signs and symptoms of hypoglycemia. D. The teaching plan should include how to administer regular insulin. E. The teaching plan should include sick day rules.

1. The client should obtain a finger-stick blood glucose reading before each meal. 2. The teaching plan should include signs and symptoms of hypoglycemia. 3. The teaching plan should include sick day rules. Rationale: All diabetic clients, regardless of type, should check finger-stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore, the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day rules. All diabetic clients should follow the American Diabetes Association diet. The teaching plan is focusing on oral antidiabetic medications; therefore, regular inulin education would not be needed.

Which client response is indicative of a hypoglycemic reaction? Select all that apply. One, some, or all responses may be correct. A. Tremors B. Anorexia C. Confusion D. Glycosuria E. Diaphoresis

1. Tremors 2. Confusion 3. Diaphoresis Rationale: Tremors are a sympathetic nervous system response that occurs because circulating glucose in the brain decreases. Confusion is typically the first sign of a hypoglycemic reaction. Diaphoresis is a cholinergic response to hypoglycemia. Hypoglycemia causes hunger, not anorexia. Because blood glucose is low in hypoglycemia, the renal threshold is not exceeded and glycosuria does not occur.

When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities among the older adult Hispanic population? Select all that apply. One, some, or all responses may be correct. A. Value differences B. Language barrier C. Lack of health care facility D. Inadequate health insurance E. Poor diet and nutrition

1. Value differences 2. Language barrier 3. Lack of health care facility 4. Inadequate health insurance Rationale: The health of Hispanic older adults lags behind their white counterparts due to a number of factors. Beliefs and values of some older Hispanic clients may conflict with traditional Western health care views. Most nurses are not educated in Spanish, and this language barrier may affect health care delivery. Lack of health care access and inadequate health insurance also contribute to disparities. Although their diets may differ, it does not necessarily mean their nutrition is poor, so this is not a contributing factor.

Which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? A. It is a congenital abnormality. B. A malignancy usually results. C. It predisposes to hydronephrosis. D. Prostate-specific antigen decreases.

It predisposes to hydronephrosis. Rationale: Inability to empty the bladder as a result of pressure exerted by the enlarging prostate on the urethra causes a backup of urine into the ureters and finally the kidneys (hydronephrosis). BPH develops over the client's life span; it is not congenital. It is uncommon for BPH to become malignant. Prostate-specific antigen will increase.

The nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? Select all that apply. One, some, or all responses may be correct. A. When the death of the client is imminent B. When the expected death of the client is within 6 months C. When the client seeks no aggressive disease management D. When a family member has signed an informed consent form E. When the client has been issued a "do not resuscitate" order

1. When the expected death of the client is within 6 months 2. When the client seeks no aggressive disease management 3. When the client has been issued a "do not resuscitate" order Rationale: Clients who do not seek aggressive disease management and are expected to die in a span of 6 months are eligible for hospice care. The client may require hospice care when he or she has signed a "do not resuscitate" order. A client who is nearing death may not receive hospice care; instead, the client receives comfort care. An informed consent form signed by a family member is not necessary for the client to receive hospice care.

Which intervention will the nurse implement when a client with stage 1 Alzheimer disease begins to demonstrate aphasia? A. Give step-by-step instructions to accomplish dressing. B. Place a calendar and clock in the client's room. C. Allow extra time for client to verbalize needs and thoughts. D. Remind client to clean and wear prescription eyeglasses.

Allow extra time for client to verbalize needs and thoughts. Rationale: Aphasia is the loss of language ability. At first, the client will have trouble finding the right words; this is frustrating for the client, so the nurse allows extra time for expression and verbalization. Aphasia will progress to a few words and then to mumbling. Step-by-step instructions would be helpful for clients who demonstrate apraxia (loss of purposeful movement) in dressing or accomplishing other activities of daily living. Calendars and clocks are helpful for disoriented clients. Use of devices such as hearing aids and eyeglasses compensates for expected changes in aging. Clients with dementia may need reminders or help with the devices.

Which clinical condition is the result of changes in the integrity of arterial walls and small blood vessels? A. Contusion B. Thrombosis C. Atherosclerosis D. Tourniquet effect

Atherosclerosis Rationale: In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

While obtaining a client's health history, which factor would the nurse identify as predisposing the client to type 2 diabetes? A. Having diabetes insipidus B. Eating low-cholesterol foods C. Being 20 pounds (9 kg) overweight D. Drinking a daily alcoholic beverage

Being 20 pounds (9 kg) overweight Rationale: Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.

Which physiological changes would the nurse expect to find in a client with a 20-year history of type 2 diabetes? A. Blurry, spotty, or hazy vision B. Arthritic changes in the hands C. Hyperactive knee and ankle jerk reflexes D. Dependent pallor of the feet and lower legs

Blurry, spotty, or hazy vision Rationale: Blurry, spotty, or hazy vision; floaters or cobwebs in the visual field; and cataracts or complete blindness can occur as a result of diabetes. Diabetic retinopathy is characterized by abnormal growth of new blood vessels in the retina (neovascularization). More than 60% of clients with type 2 diabetes have some degree of retinopathy after 20 years. Arthritic changes of the hands are not a usual complication associated with diabetes mellitus. Clients who are diabetic have peripheral neuropathy, which is characterized by hypoactive, not hyperactive, reflexes. Peripheral vascular disease is indicated by dependent rubor with pallor on elevation, not dependent pallor.

Which sign or symptom supports the nurse's suspicion that a client has overflow incontinence? A. Constant dribbling of urine B. Abrupt and strong urge to void C. Loss of urine with physical exertion D. Large amount of urine loss with each occurrence

Constant dribbling of urine Rationale: Overflow incontinence is characterized by an involuntary loss of urine due to overdistention of the bladder when the bladder's capacity reaches the maximum. This condition is characterized by bladder distention up to the level of the umbilicus and constant urine dribbling. An abrupt and strong urge to void is a clinical manifestation of urge incontinence. Stress incontinence is characterized by loss of urine with physical exertion. Urge incontinence is characterized by the loss of large amounts of urine with each occurrence.

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? A. Urticaria B. A medication reaction C. Atopic dermatitis D. Contact dermatitis

Contact dermatitis Rationale: Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens. Urticaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A medication reaction may be caused by any medication such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunological irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

Which statement would a nurse use to explain the purpose of standard precautions to the nursing assistant on a surgical unit? A. Decrease the risk of transmitting unidentified pathogens B. Used by staff when clients are suspected of having a communicable disease C. Ensure clients perform hygiene practices in a universal way D. Create categories requiring the client to follow additional precautions

Decrease the risk of transmitting unidentified pathogens Rationale: All staff members use standard precautions for all clients in all settings, regardless of their diagnosis or presumed infectiousness. Practices associated with standard precautions require health care providers, not a client, to use hand washing and personal protective equipment to protect themselves and others from body fluids. Transmission-based precautions, known as airborne, droplet, and contact precautions, are based on a client's diagnosed infection.

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? A. Atrophy of the sweat glands B. Decreased subcutaneous fat C. Stiffening of the collagen fibers D. Degeneration of the elastic fibers

Decreased subcutaneous fat Rationale: In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? A. Don an N95 respirator mask before entering the room. B. Put on a permeable gown each time before entering the room. C. Implement contact precautions and post appropriate signage. D. After finishing with client care, remove the gown first and then remove the gloves.

Don an N95 respirator mask before entering the room. Rationale: An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.

When teaching a group of older adults about differences between the common cold and influenza, the nurse would educate the clients that it is most important to communicate with the health care provider about which symptom? A. Earache B. Sneezing C. Nasal stuffiness D. Elevated temperature

Elevated temperature Rationale: Fever or an elevated temperature is common in influenza but rare in viral rhinitis (common cold). Because influenza can lead to complications such as pneumonia and older adults are at higher risk for complications, the nurse would emphasize the need to contact the health care provider about symptoms typical of influenza. Earache is a complication of viral rhinitis, but more severe complications such as pneumonia and respiratory failure occur with influenza. Sneezing is common with viral rhinitis but not as common with influenza. Nasal stuffiness is common with viral rhinitis but not tvoical of influenza.

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When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? A. Giving influenza vaccine to the client B. Having suction available during meals C. Assisting the client to take deep breaths D. Teaching about incentive spirometer use

Having suction available during meals Rationale: Because a client with difficulty swallowing is at risk for aspiration, having suction available will be the most effective intervention in preventing aspiration pneumonia. Giving the influenza vaccine is important in preventing viral pneumonia, but would not help prevent aspiration. Deep breathing is important to prevent atelectasis, but would not prevent aspiration pneumonia. Incentive spirometer use is important in preventing atelectasis, but not helpful in preventing aspiration.

Which guideline is useful for reducing disparity when caring for transgender clients? A. Learning about health care needs of homosexual clients B. Always referring to transgender clients using pronouns of the sex to which they transition C. Always referring to transgender clients using pronouns of the sex with which they were born D. Learning about the treatment options for transgender clients and requirements of follow-up care

Learning about the treatment options for transgender clients and requirements of follow-up care Rationale: To reduce disparities in the health care delivery to transgender clients, it is appropriate for the nurse to develop individual treatment plans rather than assuming all transgender clients are the same. Learning about treatment options and requirements for follow-up care for transgender clients also helps the nurse provide the best care possible. It is appropriate for the nurse to learn about the health care needs of homosexual clients when caring for this population, but transgender clients are not necessarily homosexual, so this may not apply. The nurse would not automatically assume the client wants to be referred to using pronouns of the gender with which they are living or of the sex with which they were born. Gender and sex exist on a spectrum, and the nurse would instead ask the client how they self-identify.

Which goal is a priority for a client who is unconscious after a cerebrovascular accident? A. Promoting elimination B. Maintaining the airway C. Optimizing fluid volume D. Preserving skin integrity

Maintaining the airway Rationale: The risk for an obstructed airway is the priority when a client is unconscious; reduced oxygen intake may lead to serious complications. Although important, constipation is not as life threatening as an obstructed airway. Although maintaining fluid balance is important, it is not as critical as maintaining a patent airway. Although protecting the client from skin injury is important, it is not as life threatening as an obstructed airway.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss? A. Smiling while seeing the client B. Nodding head in front of the client C. Making eye contact with the client D. Leaning forward towards the client

Making eye contact with the client Rationale: The nurse would make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help build a positive relationship. Nodding in front of the client helps regulate the conversation. Leaning forward towards the client shows attention and awareness.

Which infection requires airborne precautions? A. Measles B. Influenza C. Clostridium difficile D. Bacterial meningitis

Measles Rationale: Varicella, measles, and tuberculosis require airborne precautions because these infections spread through small particles in the air. Droplet precautions are implemented to prevent the spread of influenza and bacterial meningitis. C. difficile requires the use of contact precautions.

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? A. Severe right calf pain B. Right calf redness and swelling C. Oxygen saturation 89% D. Heart rate of 136 beats/minute

Oxygen saturation 89% Rationale: Low oxygen saturation in the setting of venous thrombosis may indicate pulmonary embolism, which will require rapid interventions, such as actions to improve oxygenation. Severe right calf pain is consistent with the client diagnosis of right calf venous thrombosis. Right calf redness and swelling are consistent with a diagnosis of right calf venous thrombosis. The elevated heart rate may be due to pulmonary embolism, and improvement of oxygen saturation would also decrease the heart rate.

Which responses would alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? A. Flaccid paralysis and numbness B. Absence of sweating and pyrexia C. Escalating tachycardia and shock D. Paroxysmal hypertension and bradycardia

Paroxysmal hypertension and bradycardia Rationale: An exaggerated response of the autonomic nervous system causes paroxysmal hypertension and bradycardia. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Escalating tachycardia and shock do not occur; bradycardia and hypertension occur.

Which nursing action would be a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia? A. Place in a sitting position. B. Give nifedipine as prescribed. C. Examine for symptoms of pressure injuries. D. Monitor blood pressure (BP) every 10 to 15 minutes.

Place in a sitting position. Rationale: Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high BP. The first step in this situation is to assist the client into a sitting position because it naturally reduces BP. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure injuries after stabilizing the client. The nurse would monitor client's BP every 10 to 15 minutes after stabilizing the client.

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? A. Place objects within the visual field. B. Teach passive range-of-motion exercises. C. Instill artificial teardrops into the affected eye. D. Reduce time client is positioned on the left side.

Place objects within the visual field. Rationale: A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

Which condition is due to decreased elasticity of the ocular lens? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

Presbyopia Rationale: Presbyopia is an age-related problem in which the lens loses its elasticity and is less able to change its shape to focus the eye for close work. As a result, images fall behind the retina. Myopia, or nearsightedness, is a condition in which the eye overrefracts the light and the bent images fall in front of, not on, the retina. Hyperopia, also called hypermetropia or farsightedness, is a condition in which refraction is too weak, causing images to be focused behind the retina. Astigmatism occurs when the curve of the cornea is uneven. Because light rays are not refracted equally in all directions, the image does not focus on the retina.

When interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client's perception of pain? A. Age and sex B. Physical and physiological status C. Intelligence and economic status D. Previous experience and cultural values

Previous experience and cultural values Rationale: Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain, so it can be tolerated better, but it does not affect the perception of intensity. Economic status has no effect on pain perception.

Which disorder would the nurse suspect when a client (see image) presents with thick skin scales and inflammation on the neck and reports that the lesions must be spreading because they are usually on the knees and elbows? A. Lentigo B. Psoriasis C. Acne vulgaris D. Seborrheic keratoses

Psoriasis Rationale: The image depicts psoriasis. This condition is a chronic autoimmune dermatitis that involves the excessively rapid turnover of epidermal cells. Characteristic scaling and inflammation are present on the skin. Lentigo is a condition in which hyperpigmented, brown-to-black macules or patches are present on the skin. Acne vulgaris includes papules and pustules on the face, neck, and upper back. Seborrheic keratoses are irregularly round or oval papules or plaques on the skin.

Which possible complication would a nurse monitor for when a client develops a venous thrombosis in the left calf? A. Embolic stroke B. Pulmonary embolism C. Myocardial infarction D. Ischemia of the left foot

Pulmonary embolism Rationale: Because the venous system returns blood to the right side of the heart and then blood flows to the pulmonary circulation, emboli from the venous thrombosis may cause a pulmonary embolism. Embolic stroke occurs with thrombus formation in the left atrium or ventricle. Myocardial infarction occurs when thrombus forms over ruptured coronary artery plaque. Ischemia of the foot would occur with an embolus in the distal arterial system.

Which action would the nurse take next when a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment? A. Teach the client about the need for a low sodium diet. B. Ask the client when blood pressure medications were taken last. C. Question the client about symptoms such as headache or chest pain. D. Call for an ambulance to transport the client to the emergency department.

Question the client about symptoms such as headache or chest pain. Rationale: The nurse's initial action would be to determine if the client is having symptoms that might indicate acute complications such as stroke or acute coronary syndrome. The client may need teaching about dietary sodium reduction, but more assessment is needed before the nurse implements teaching. Failure to take blood pressure medications is a common reason that clients have sudden increases in blood pressure, but it is more important to determine if the client is having complications caused by the elevated blood pressure. If the client is having symptoms of stroke or acute coronary syndrome, an ambulance would be called for transport to the hospital, but an elevated blood pressure alone is not an indicator of a need for emergency services.

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? A. Pouring warm water over the perineum B. Ensuring the patency of the catheter C. Removing the catheter within 24 hours D. Cleaning the catheter insertion site

Removing the catheter within 24 hours Rationale: Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours if the client does not need it. Removing the catheter within 24 hours would be the best intervention. Although pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.

Which finding of a client several hours after removal of a catheter inserted a week prior after pelvic surgery indicates a need for reinsertion of the catheter? A. Anuria B. Polyuria C. Retention D. Incontinence

Retention Rationale: The inability of the client to urinate in spite of the bladder being filled with urine is called retention. Generally, clients who have undergone pelvic surgery and have the catheter removed experience urinary retention. The catheter should be reinserted if the client is unable to void. Anuria is the drastic decrease in urine output to less than 100 mL in a day and is a sign of end-stage kidney disease or acute kidney injury. Polyuria is anticipated in a client who is diagnosed with diabetes mellitus or insipidus, and the client eliminates large volumes of urine at a time. Incontinence or the loss of ability over voluntarily control of urination is a sign of conditions such as neurogenic bladder or bladder infection.

Which eye problem is the leading cause of blindness in clients with diabetes? A. Cataracts B. Glaucoma C. Retinopathy D. Astigmatism

Retinopathy Rationale: Diabetic retinopathy is a leading cause of blindness in diabetics. Glaucoma and cataracts also are associated with diabetes, but retinopathy is the most common eye problem. Astigmatism is not associated with diabetes.

Which clinical finding would the nurse expect for a client with hypertensive emergency? A. Increased urine output B. Severe pounding headache C. Heart rate 110 beats/minute D. Weak and thready radial pulses

Severe pounding headache Rationale: Hypertensive emergency often causes hypertensive encephalopathy because of increased cerebral capillary permeability, leading to severe headache, nausea, vomiting, and confusion or coma. Increased urine output would not be expected because acute kidney injury can occur with hypertensive emergency. Tachycardia is not typically seen with hypertensive emergency; high blood pressure can lead to bradycardia because of increased pressure on the carotid sinus and bodies. Radial pulses would be bounding with hypertensive emergency.

Which description of pain would the nurse expect a client with a ureteral calculus to report? A. Boring-type pain that is located in the flank B. Dull and constant at the costovertebral angle C. Located at the level of the kidneys and occurring with each urination D. Spasmodic and radiating from the side to the suprapubic area

Spasmodic and radiating from the side to the suprapubic area Rationale: Pain with ureteral stones is caused by spasm (renal colic) and is excruciating and intermittent; it follows the path of the ureter to the bladder down to the groin. Pain is spasmodic and excruciating, not boring, dull, or constant. Pain intensifies as the calculus lodges in the ureter and spasms occur in an attempt to dislodge it. Pain at the costovertebral angle can indicate urinary tract infection. The pain is episodic and not located at the level of the kidneys.

Which type of impairment does the nurse expect the client who has expressive aphasia to exhibit? A. Speaking or writing B. Following instructions C. Understanding speech or writing D. Recognizing words for familiar objects

Speaking or writing Rationale: Damage to Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech, like speaking and writing. Expressive aphasia is associated with injury in the Broca area. Impairments such as following specific instructions, understanding speech or writing, and recognizing words for familiar objects are associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of Wernicke area of the brain.

Which type of incontinence can be improved by teaching the client Kegel exercises? A. Reflex incontinence B. Stress incontinence C. Overflow incontinence D. Functional incontinence

Stress incontinence Rationale: Stress incontinence is the involuntary loss of urine during coughing, laughing, or sneezing. In women, this is often seen after having children. Kegel exercises increase the perineal muscle tone, helping control involuntary voiding. Reflex incontinence is preceded by abnormal detrusor contractions from neurological abnormalities. Overflow incontinence is caused by overdistention of the bladder, and exercises will not help. Functional incontinence is associated with environmental or cognitive factors due to which the client is unable to get to the toilet or does not have the necessary cognitive abilities to use the toilet.

A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which clinical manifestations would the nurse assess? A. Suprapubic distention B. Increased spinal reflexes C. Adventitious breath sounds D. Imminent development of shock

Suprapubic distention Rationale: Suprapubic distention is a symptom of autonomic dysreflexia, which is commonly precipitated by a distended bladder. Increased spinal reflexes and adventitious breath sounds are not associated with the symptoms of autonomic dysreflexia. The blood pressure increases suddenly with autonomic dysreflexia.

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)? A. The injury results in loss of the reflex arc. B. The injury is above the sixth thoracic vertebra. C. There has been a partial transection of the cord. D. There is a flaccid paralysis of the lower extremities.

The injury is above the sixth thoracic vertebra. Rationale: The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. Which explanation would the nurse give for why a PEG tube is preferred for administering a tube feeding? A. There is less chance of aspiration with a PEG tube. B. The PEG tube does not require a pump. C. Self-administration of the tube feeding is possible. D. More tube feeding mixture can be given each time.

There is less chance of aspiration with a PEG tube. Rationale: When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, and cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

The nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions? A. They keep the child away from uninfected people. B. The infectious process is interrupted as quickly as possible. C. The child is protected from contracting a secondary infection. D. They prevent the development of a hospital-acquired infection.

They keep the child away from uninfected people. Rationale: Droplet precautions reduce the transmission of infection from the child to other individuals (cross-infection). The microorganisms are transmitted to others in respiratory droplets. Droplet precautions do not interrupt the infectious process; they protect those in contact with the child from contracting the infection. Droplet precautions do not protect the child from contracting secondary infections; they protect others from being exposed to the child's pathogens. Thorough hand washing and aseptic techniques, not droplet precautions, limit the spread of hospital-acquired infections.

Which focus would the nurse associate with hospice care? A. To ease the pain from illness B. To provide curative treatment C. To assist with activities of daily living D. To adapt to the limitations due to an illness

To ease the pain from illness Rationale: The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a homelike environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client adapt to the limitations caused by the illness.

Which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? A. Stage I B. Stage II C. Stage IIII D. Unstageable

Unstageable Rationale: A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage Il pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage Ill pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients? A. Sensory deprivation. B. Urinary tract infection C. Frequent use of diuretics D. Inaccessibility of a bathroom

Urinary tract infection Rationale: Urinary incontinence in older adults can be a sign of urinary tract infection. Urinary tract infections affect the genitourinary tract and interfere with voluntary control of micturition. Sensory deprivation is a neurological, not a genitourinary, factor. Frequent use of diuretics is an iatrogenic, not genitourinary, factor. Inaccessibility of a bathroom is an environmental, not genitourinary, factor.