NCLEX questions exam 2

The nurse provides information to a client diagnosed with insulin- dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply. 1. Hunger 2. Sweating 3. Weakness 4. Nervousness 5. Cool clammy skin 6. Increased urinary output

A: 1. Hunger 2. Sweating 3. Weakness 4. Nervousness 5. Cool clammy skin R: Hypoglycemia is characterized by a blood glucose level less than 70 mg/dL (4 mmol/L). Clinical manifestations of hypoglycemia include hunger, sweating, weakness, nervousness, cool clammy skin, blurred vision or double vision, tachycardia, and palpitations. Increased urinary output is a manifestation of hyperglycemia.

A 16-year-old client diagnosed with diabetes is admitted for hyperglycemia. The client states, "I'm fed up with having my life ruled by diets, doctors' prescriptions, and machines!" Based on this assessment data, which is the priority client concern? 1. A chronic illness 2. A personal crisis 3. Feelings of loss of control 4. Lack of understanding about nutrition

3. Feelings of loss of control R: Adolescents strive for identity and independence, and the situation describes a common fear of loss of control. Therefore, the priority problem relates to these feelings of loss of control. Although the child has a chronic illness and may be experiencing a personal crisis, the child's statement focuses on loss of control. There is no information in the question that indicates a lack of knowledge.

After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands? 1. Fever 2. Neck pain 3. Hoarseness 4. Tingling around the mouth

A: Tingling around the mouth R: The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Fever may be expected in the immediate postoperative period but is not an indication of damage to the parathyroid glands. However, if a fever persists the primary health care provider is notified. Neck pain and hoarseness are expected findings postoperatively.

The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse should ensure that which specific priority item is at the client's bedside? 1. Cardiac monitor 2. Tracheotomy set 3. Intermittent gastric suction 4. Underwater seal chest drainage system

A: Tracheostomy set R: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure.

A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply. 1. Thyroxine (T4) 2. Prolactin (PRL) 3. Triiodothyronine (T3) 4. Growth hormone (GH) 5. Luteinizing hormone (LH) 6. Adrenocorticotropic hormone (ACTH)

A: 1. Thyroxine (T4) and 3. Triiodothyronine (T3) R: Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production.

The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure

A: 1. Reflexes R: Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery. Blood pressure would provide good information about recovery from other types of shock, but not spinal shock.

The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction? 1. Weak pedal pulses 2. Drainage at the pin sites 3. Complaints of leg discomfort 4. Toes demonstrating a brisk capillary refill

A: 1. Weak pedal pulses R:Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.

The nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus. The nurse should recognize that which teaching plan component is most important initially? 1. Knowledge of the diabetic diet 2. Understanding of the diagnosis 3. Monitoring of blood glucose levels 4. Correct technique for administering insulin

A: 2. Understanding of the diagnosis R: Before educating about a disease process, it is important that the client understands the components of the disease process. After this teaching, the actual components of diet, blood glucose testing, and insulin injections can be taught.

The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding? 1. "I may become diaphoretic and faint." 2. "I may notice signs of fatigue, dry skin, and increased urination." 3. "I need to take an extra diabetic pill if my blood glucose is greater than 300." 4. "I should restrict my fluid intake if my blood glucose is greater than 250."

A: "I may notice signs of fatigue, dry skin, and increased urination" R: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.

When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem? 1. "Avoid caffeine in your diet." 2. "Take your temperature every day." 3. "Limit your fluid intake to 1000 mL per 24 hours." 4. "Catheterize yourself every 2 hours as needed to prevent spasm."

A: 1. "Avoid caffeine in your diet." R: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.

The clinic nurse instructs a client diagnosed with diabetes mellitus about preventing diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching? 1. "I need to stop my insulin if I am vomiting." 2. "I need to call my doctor if I am ill for more than 24 hours." 3. "I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours." 4. "I need to drink small quantities of fluid every 15 to 30 minutes."

A: 1. "I need to stop my insulin if I am vomiting." R: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The client needs to be instructed to take insulin, even if he or she is vomiting and unable to eat. It is important to self-monitor blood glucose more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is more than 250 mg/dL, the client should test for urine ketones and contact the primary health care provider. All the remaining options are accurate interventions.

A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder? 1. Hypokalemia 2. Hyperglycemia 3. Decreased plasma cortisol levels 4. Low white blood cell (WBC) count

A: 2. Hyperglycemia R: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.

The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply. 1. "If I am ill, I should skip my daily dose." 2. "If I overeat, I will double my dosage of medication." 3. "Oral agents are effective in managing type 2 diabetes." 4. "If I become pregnant, I will discontinue my medication." 5. "Oral hypoglycemic medications will cause my urine to turn orange." 6. "My medications are used to manage my diabetes along with diet and exercise."

A: 1. "If I am ill, I should skip my daily dose." 2. "If I overeat, I will double my dosage of medication." 4. "If I become pregnant, I will discontinue my medication." 5. "Oral hypoglycemic medications will cause my urine to turn orange." R: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.

The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary? 1. "If he is vomiting, I shouldn't give him any insulin." 2. "I should bring him to the doctor if he develops a fever." 3. "If our grandchildren are sick, they probably shouldn't come to visit." 4. "I should call the doctor if he has nausea or abdominal pain lasting for more than 1 or 2 days."

A: 1. "If he is vomiting, I shouldn't give him any insulin." R: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Priority

A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report? 1. Amenorrhea 2. Menorrhagia 3. Metrorrhagia 4. Dysmenorrhea

A: 1. Amenorrhea R: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.

The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client to manage emotional stressors by using mental imaging. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone orally per the primary health care provider's prescription.

A: 1. Assist the client to develop a daily bowel routine to prevent constipation. R: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.

The nurse is admitting a client with a diagnosis of hypothyroidism. What assessment should the nurse perform to obtain data related to this diagnosis? 1. Inspect facial features. 2. Auscultate lung sounds. 3. Percuss the thyroid gland. 4. Inspect ability to ambulate safely.

A: 1. Inspect facial features R: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristics of hypothyroidism. The assessment techniques in options 2, 3, and 4 will not reveal information related to the diagnosis of hypothyroidism.

Which medication instructions should the nurse provide to a client who has been prescribed levothyroxine? Select all that apply. 1. Monitor your own pulse rate. 2. Take the medication in the morning. 3. Take the medication at the same time each day. 4. Notify the primary health care provider if chest pain occurs. 5. Expect the pulse rate to be greater than 100 beats per minute. 6. It may take 1 to 3 weeks for a full therapeutic effect to occur.

A: 1. Monitor your own pulse rate. 2. Take the medication in the morning. 3. Take the medication at the same time each day. 4. Notify the primary health care provider if chest pain occurs. 6. It may take 1 to 3 weeks for a full therapeutic effect to occur. R: Levothyroxine is a thyroid hormone. The client is instructed to monitor her or his own pulse rate. The client is also instructed to take the medication in the morning before breakfast to prevent insomnia and to take the medication at the same time each day to maintain hormone levels. The client is told not to discontinue the medication and that thyroid replacement is lifelong. Additional instructions include contacting the primary health care provider if the rate is greater than 100 beats per minute and notifying the primary health care provider if chest pain occurs, or if weight loss, nervousness and tremors, or insomnia develops. The client is also told that full therapeutic effect may take 1 to 3 weeks and that he or she needs to have follow-up thyroid blood studies to monitor therap

A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs? 1. Numbness and tingling are felt in the fingers. 2. The cast feels heavy and damp after 24 hours of application. 3. The entire cast feels warm during the first 24 hours after application. 4. Slightly bloody drainage is noted on the cast during the first 6 hours after application.

A: 1. Numbness and tingling are felt in the fingers. R: A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs/symptoms of increased pressure from the cast include numbness, tingling, and increased pain. A cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.

The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge? 1. The client jokes about no longer needing to worry about birth control. 2. The client states that she will be careful to not eat as many dairy products. 3. The client verbalizes the need to eat her meals at the same time every day. 4. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization.

A: 1. The client jokes about no longer needing to worry about birth control. R: Female spinal cord trauma clients remain fertile during their reproductive years, and contraception is necessary for those who are sexually active. However, oral contraceptives may increase the risk for thrombophlebitis. Clients with paralysis should avoid dairy products to control the formation of urinary calculi. Meals should be eaten at the same time every day, and they should include fiber and warm solid and liquid foods to promote and maintain the regular evacuation of the bowel. Clients who lack bladder control are taught to self-catheterize using clean technique.

The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply. 1. Wear support or elastic stockings. 2. Wear well-fitted shoes and walk barefoot when at home. 3. Wear dark-colored stockings or socks and change them daily. 4. Use a heating pad set at low setting on the feet if they feel cold. 5. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6. Wash the feet and legs with mild soap and water and rinse and dry them well.

A: 1. Wear support or elastic stockings. 5. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6. Wash the feet and legs with mild soap and water and rinse and dry them well. R: Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider, wearing white or colorfast stockings or socks and changing them daily, checking the temperature of the bath water with a thermometer before putting the feet into the water, avoiding the use of heat (hot foot soaks, heating pad, hot water bottle) on the feet because of the risk of burning, avoiding the use of sharp devices to cut nails, and wearing well-fitted shoes and avoiding going barefoot.

The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement? 1. "I need to eat foods low in potassium." 2. "I need to check the color of my stools." 3. "I need to check the temperature of my legs twice a day." 4. "I need to take aspirin rather than acetaminophen for a headache."

A: 2. "I need to check the color of my stools." R: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.

Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety? 1. "I'm so angry that this happened to me." 2. "I really don't want to live my life like this." 3. "I'm definitely not looking forward to going home." 4. "I don't know if I can make all these major adjustments to my life."

A: 2. "I really don't want to live my life like this." R: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness

A client has fallen and sustained a leg injury. Which question should the nurse ask to help determine if the client sustained a fracture? 1. "Is the pain a dull ache?" 2. "Is the pain sharp and continuous?" 3. "Does the discomfort feel like a cramp?" 4. "Does the pain feel like the muscle was stretched?

A: 2. "Is the pain sharp and continuous?" R: Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching or overextension.

A young adult client diagnosed with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again." Which is the realistic reply for the nurse to make to the client? 1. "It must feel horrible to know you can never have sex again." 2. "It's still possible to have a sexual relationship, but it will be different." 3. "You're young, so you'll adapt to this more easily than if you were older." 4. "Because of body reflexes, sexual functioning will be no different than before."

A: 2. "It's still possible to have a sexual relationship, but it will be different." R: It is possible to have a sexual relationship after a spinal cord injury, but it is different from what the client will have experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after a spinal cord injury.

The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed? 1. Dextran 2. 0.9% normal saline 3. 5% dextrose in water 4. 5% dextrose in 0.9% normal saline

A: 2. 0.9% normal saline R: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.

A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply. 1. Weight loss 2. Bradycardia 3. Hypotension 4. Dry, scaly skin 5. Heat intolerance 6. Decreased body temperature

A: 2. Bradycardia 3. Hypotension 4. Dry, scaly skin 6. Decreased body temperature Level of Cognitive R:The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.

The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse should determine that there is a need for close observation and a need for follow-up if which is noted? 1. Palpable pulses distal to the cast 2. Capillary refill greater than 6 seconds 3. Blanching of the nail bed when it is depressed 4. Sensation when the area distal to the cast is pinched

A: 2. Capillary refill greater than 6 seconds R: To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches, and then the pressure is released. This is known as capillary refill time. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and follow-up. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the primary health care provider should be notified.

The nurse is assigned to care for a client who is in traction. Which intervention by the nurse should ensure a safe environment for the client? 1. Making sure that the knots are at the pulleys sites 2. Checking the weights to be sure that they are off the floor 3. Making sure that the head of the bed is kept at a 90-degree angle 4. Monitoring the weights to be sure that they are resting on a firm surface

A: 2. Checking the weights to be sure that they are off the floor R: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. The head of the bed is usually kept low to provide countertraction. Weights are not to be kept resting on a firm surface

The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites? 1. Loose but intact pin sites 2. Clear drainage from the pin sites 3. Purulent drainage from the pin sites 4. Redness and swelling around the pin sites

A: 2. Clear drainage from the pin sites R: A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.

Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply. 1. Irritability 2. Hoarse cry 3. Bradycardia 4. Constipation 5. Fused fontanels 6. Excessive sleeping

A: 2. Hoarse cry 3. Bradycardia 4. Constipation 6. Excessive sleeping R: The infant with congenital hypothyroidism may display the following signs: skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, bradycardia, and a distended abdomen. Other signs and symptoms include prolonged jaundice, lethargy, constipation, feeding problems, coldness to touch, umbilical hernia, hoarse cry, and excessive sleeping.

The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan? 1. Assisting the client to deal with long-term care placement 2. Including the client's significant others in the teaching session 3. Following up on laboratory and diagnostic tests that were prescribed 4. Including information the primary health care provider has indicated

A: 2. Including the client's significant others in the teaching session R: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.

The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? Select all that apply. 1. Lift the cast using the fingertips. 2. Place the child on a firm mattress. 3. Direct a fan toward the cast to facilitate drying. 4. Support the cast and adjacent joints with pillows. 5. Place the extremity with the cast in a dependent position. 6. Reposition the extremity with the cast every 2 to 4 hours.

A: 2. Place the child on a firm mattress. 3. Direct a fan toward the cast to facilitate drying. 4. Support the cast and adjacent joints with pillows. 6. Reposition the extremity with the cast every 2 to 4 hours. R: To help the cast dry, the child should be placed on a firm mattress. A fan may be directed toward the cast to facilitate drying. Once the cast is dry, the cast should sound hollow and be cool to touch. The cast and adjacent joints should be elevated and supported with pillows. To ensure thorough drying, the extremity with the cast should be repositioned every 2 to 4 hours. The cast is lifted by using the palms of the hands (not the fingertips) to prevent indentation in the wet cast surface. Indentations could possibly cause pressure on the skin under the cast.

A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure? 1. Mole skin-lined heel protectors 2. Regular use of posterior splints 3. Application of pneumatic boots 4. Avoiding dorsal flexion of the foot

A: 2. Regular use of posterior splints R: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.

The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken? 1. Wear a clean nylon sock over the residual limb every day. 2. Use a mirror to inspect all areas of the residual limb each day. 3. Toughen the skin of the residual limb by rubbing it with alcohol. 4. Prevent cracking of the skin of the residual limb by applying lotion daily.

A: 2. Use a mirror to inspect all areas of the residual limb each day. R: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also

A client who is in halo traction states to the visiting nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which therapeutic response should the nurse make to the client? 1. "If I were you, I would have had the surgery rather than suffer like this." 2. "No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously." 3. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." 4. "Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?"

A: 3. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." R: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.

A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response? 1. "It means the fracture is incomplete." 2. "It means the bone is partially fractured." 3. "It means the bone fractured with splintering of the bone into fragments." 4. "It means the skin or mucous membrane was broken when the fracture occurred."

A: 3. "It means the bone fractured with splintering of the bone into fragments." R: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone

The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching? 1. "It is best if I avoid tight clothing and lumpy bedclothes." 2. "I should watch for headache, congestion, and flushed skin." 3. "Signs/symptoms I should watch for include fever and chest pain." 4. "I need to pay close attention to how frequently my bowels move."

A: 3. "Signs/symptoms I should watch for include fever and chest pain." R: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition. Priority Nursing Tip: Trigge

The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse should teach the client to report glucose levels that consistently exceed which level? 1. 150 mg/dL (8.57 mmol/L) 2. 200 mg/dL (11.42 mmol/L) 3. 250 mg/dL (14.28 mmol/L) 4. 350 mg/dL (20.0 mmol/L)

A: 3. 250 mg/dL (14.28 mmol/L) R: The normal blood glucose level ranges from 70 to 110 mg/dL (4 to 6 mmol/L), or as designated and preferred by the primary health care provider. The client with diabetes mellitus should be taught to report blood glucose levels that exceed 250 mg/dL (14.28 mmol/L), unless otherwise instructed by the primary health care provider. Options 1 and 2 are high levels but do not require primary health care provider notification. Option 4 is a high value; the client should report an elevated level before it reaches this point. Priority Nursing Tip: Self-monitoring of the blood glucose l

The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond? 1. A bone fragment has injured the nerve supply in the area. 2. An injured artery causes impaired arterial perfusion through the compartment. 3. Bleeding and swelling cause increased pressure in an area that cannot expand. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

A: 3. Bleeding and swelling cause increased pressure in an area that cannot expand. R: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.

Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention? 1. Polyuria, nausea, and severe headaches 2. Polydipsia, translucent skin, and obesity 3. Fever, tachycardia, and systolic hypertension 4. Profuse diaphoresis, flushing, and constipation

A: 3. Fever, tachycardia, and systolic hypertension R: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.

A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis? 1. Hypovolemia 2. Hypoglycemia 3. Mood disturbances 4. Deficient fluid volume

A: 3. Mood disturbances R: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension

The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply. 1. Vital signs 2. Bilateral lung sounds 3. Pulse in the affected extremity 4. Level of pain in the affected leg 5. Skin color of the affected extremity 6. Capillary refill of the affected toes

A: 3. Pulse in the affected extremity 4. Level of pain in the affected leg 5. Skin color of the affected extremity 6. Capillary refill of the affected toes R: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.

The nurse is teaching a client with a right-leg fracture who has a prescription for partial weight-bearing status how to ambulate with crutches. The nurse determines that the client demonstrates compliance with this restriction to prevent complications of the fracture if the client follows which direction? 1. Allows the right foot to only touch the floor 2. Does not bear any weight on the right leg/foot 3. Puts 30% to 50% of the weight on the right leg/foot 4. Puts 60% to 80% of the weight on the right leg/foot

A: 3. Puts 30% to 50% of the weight on the right leg/foot R: The client who has partial weight-bearing status is allowed to place 30% to 50% of the body weight on the affected limb. Touchdown weight- bearing allows the client to let the limb touch the floor but not to bear weight. Non-weight-bearing status does not allow the client to let the limb touch the floor. There is no classification for 60% to 80% weight-bearing status. Full weight-bearing status involves placing full weight on the limb.

A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, "My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?" Which therapeutic response should the nurse make to the client's daughter? 1. "Tell me what you think you did wrong." 2. "Maybe we can keep your father in the hospital for a while longer to give you a rest." 3. "You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care." 4. "An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed."

A: 4. "An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed." R: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.

The nurse requests that a client with a diagnosis of diabetes mellitus ask family members to attend an educational conference about the administration of insulin. The client questions why they need to be included. Which statement is best for the nurse to respond? 1. "Family members are at risk of developing diabetes." 2. "Family members can take you to your appointments." 3. "Nurses will need someone to call and check on a client's progress." 4. "Families often work together towards the successful management of diabetes."

A: 4. "Families often work together towards the successful management of diabetes." R: Families and significant others may be included in diabetes education to assist with adjustments of the diabetic regimen. Having positive family members involved will be a support to the client in assuming independent care. Although the other options are not incorrect, they do not reinforce the importance of family involvement in the client's care.

A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with hyperglycemia. During the assessment, the client states to the nurse, "I'm sorry to keep bothering you every day, but I just can't give myself those awful shots." Which therapeutic comment is most appropriate for the nurse to respond? 1. "I couldn't give myself a shot either." 2. "You must learn to give yourself the shots." 3. "Let me see if we can change your medication." 4. "Have you had instructions on injecting yourself?

A: 4. "Have you had instructions on injecting yourself?" R: It is important to determine and deal with a client's underlying fear of self-injection. The nurse should determine whether a knowledge deficit exists. Positive reinforcement should occur rather than focusing on negative behaviors. Demanding that the client perform a behavior or skill is inappropriate. The nurse should not offer a change in regimen that cannot be accomplished.

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

A: 4. "I can use a hair dryer on the low setting and allow the air to blow into the cast." R: Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin and providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with the forceful injection of air inside the cast.

An older client has been admitted to the hospital diagnosed with a hip fracture. The nurse prepares a plan of care for the client and identifies desired outcomes related to surgery and impaired physical mobility. Which statement by the client supports a positive adjustment to the surgery and impairment in mobility? 1. "Hurry up and go away. I want to be alone." 2. "What took you so long? I called for you 30 minutes ago." 3. "I wish you nurses would leave me alone! You are all telling me what to do!" 4. "I find it a little difficult to concentrate since the surgeon talked with me about the surgery tomorrow."

A: 4. "I find it a little difficult to concentrate since the surgeon talked with me about the surgery tomorrow." R: Option 4 reflects an individual with moderate anxiety caused by a difficulty to concentrate. It most appropriately supports a positive adjustment. Option 1 demonstrates withdrawal behavior. Option 2 is a demanding response. Option 3 demonstrates acting out by the client. Demanding, acting out, and withdrawn clients have not coped with or adjusted to the injury or disease.

The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which statement by the client indicates the need for further teaching? 1. "Hypoglycemia can occur at any time of the day or night." 2. "I should drink 6 to 8 ounces of milk if hypoglycemia occurs." 3. "If I feel sweaty or shaky, I might be experiencing hypoglycemia." 4. "If hypoglycemia occurs, I need to take my regular insulin as prescribed."

A: 4. "If hypoglycemia occurs, I need to take my regular insulin as prescribed." R: Hypoglycemia can occur when the blood glucose level falls below 70 mg/dL (4 mmol/L). Insulin is not taken as a treatment for hypoglycemia because the insulin will lower the blood glucose level. Hypoglycemic reactions can occur at any time of the day or night. If a hypoglycemic reaction occurs, the client will need to consume 10 to 15 g of carbohydrate; 6 to 8 ounces of milk, for example, contain this amount of carbohydrate. Tremors and diaphoresis are signs of mild hypoglycemia.

The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding? 1. A normal value that indicates that the client is managing blood glucose control well 2. A value that does not offer information regarding the client's management of the disease 3. A low value that indicates that the client is not managing blood glucose control very well 4. A high value that indicates that the client is not managing blood glucose control very well

A: 4. A high value that indicates that the client is not managing blood glucose control very well R: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management 1 to 2 days before the test is done. The glycosylated hemoglobin level should be 6.0% or less for a client diagnosed with diabetes mellitus, with elevated levels indicating poor glucose control.

The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first? 1. Structure menus for adherence to diet. 2. Teach with videotapes showing insulin administration to ensure competence. 3. Encourage dependence on others to prepare the client for the chronicity of the disease. 4. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment.

A: 4. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment R: The nurse first assesses the client's ability for self-care. Structuring menus for the client promotes dependence. Allowing the client to have hands- on experience rather than teaching with videos is more effective. Independence should be encouraged.

The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety? 1. Monitoring for heel breakdown 2. Monitoring for bladder distention 3. Monitoring for extremity shortening 4. Monitoring for blanching ability of toe nail beds

A: 4. Monitoring for blanching ability of toe nail beds R: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.

A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge teaching plan for the client and identifies which intervention as a priority? 1. Exercise routines 2. Controlling dietary intake 3. Keeping follow-up appointments 4. Monitoring for signs/symptoms of dehydration

A: 4. Monitoring for signs/symptoms of dehydration R: Clients at risk for HHS should report signs and symptoms of dehydration to primary health care providers. Dehydration can be severe, and it may progress rapidly. Although exercising, dietary modifications, and follow- up appointments are components of the teaching plan, for the client diagnosed with HHS, dehydration is the priority. Priority Nursing Tip: Hyperglycemic

The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? 1. Dependent edema 2. Diminished distal pulse 3. Coolness and pallor of the skin 4. Presence of warm areas on the cast

A: 4. Presence of warm areas on the cast R:

The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action should the nurse implement when preparing the client to sit in a chair? 1. Apply knee splints to stabilize the joints during transfer. 2. Teach the client to lock the knees during the pivoting stage of the transfer. 3. Administer a vasodilator in order to improve circulation of the lower limbs. 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.

A: 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes. R: Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem.

A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation? 1. A body image disturbance 2. Attention-seeking behavior 3. Opposition to authority figures 4. Regressing to earlier developmental behavior

A: 4. Regressing to earlier developmental behavior R: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.

The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Ask the laboratory to perform electrolyte studies. 4. Reorient the client to time, place, and person frequently.

A: 4. Reorient the client to time, place, and person frequently. R: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

A parent of a 9-year-old child newly diagnosed with diabetes mellitus is very concerned about the child going to school and participating in social events. The nurse creating a plan of care should formulate which goals to address these concerns? Select all that apply. 1. The child's normal growth and development will be maintained. 2. The child will use effective coping mechanisms to manage anxiety. 3. The child and family will discuss all aspects of the illness and its treatments. 4. The child and family will integrate diabetes care into patterns of daily living. 5. The child and family will discuss their concerns with the child's teachers and the school nurse.

A: 4. The child and family will integrate diabetes care into patterns of daily living. 5. The child and family will discuss their concerns with the child's teachers and the school nurse. R: To effectively manage social events in the child's life, the family and the child need to integrate the care and management of diabetes into their daily living. In addition, the child's teachers and the school nurse should be aware of their concerns. The other options may be appropriate goals, but they do not deal with social issues

The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method? 1. Placing ice on top of the cast 2. Supporting the cast with the fingertips only 3. Asking the client to support the cast during transfer 4. Using the palms of the hands and soft pillows to support the cast

A: 4. Using the palms of the hands and soft pillows to support the cast R: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)? 1. An apnea monitor 2. A suction unit and oxygen 3. A blood transfusion warmer 4. An ampule of phytonadione

A: A suction unit and oxygen R: After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Phytonadione would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration.

An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure? 1. Try to swallow. 2. Hold your breath. 3. Breathe normally. 4. Roll the tongue to the back of the mouth.

A: Breathe normally R: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway.

The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury? 1. Hypothermia blanket 2. Emergency tracheostomy kit 3. Magnesium sulfate in a ready-to-inject vial 4. Ampule of saturated solution of potassium iodide

A: Emergency tracheostomy kit R: Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state

The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem? 1. Immobility 2. Risk of infection 3. Altered independence 4. Insufficient sensory stimulation

A: Immobility R: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.

The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information should the nurse share with the client about the therapy? 1. After the initial dose, subsequent treatments must continue lifelong. 2. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose. 3. It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease. 4. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.

A: It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease R: Graves' disease is also known as toxic diffuse goiter and is characterized by a hyperthyroid state resulting from hypersecretion of thyroid hormones. After treatment with radioactive iodine therapy, a decrease in the thyroid hormone level should be noted, which helps alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. Occasionally, a client may require a second or third dose, but treatments are not lifelong. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse must reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates.

The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow? 1. Keep glucose tablets. 2. Monitor the urine for acetone. 3. Report any feelings of drowsiness. 4. Omit the evening dose of NPH insulin if the client has been exercising.

A: Keep glucose tablets R: Glucose tablets are taken if a hypoglycemic reaction occurs. Glucagon is also a medication that may be prescribed to be administered subcutaneously or intramuscularly if the client loses consciousness and is unable to take glucose by mouth. Glucagon releases glycogen stores and raises the blood glucose levels of hypoglycemic clients. Family members can be taught to administer this medication and possibly to prevent an emergency department visit. Acetone in the urine may indicate hyperglycemia. Although signs/symptoms of hypoglycemia need to be taught to the client, drowsiness is not the initial and key sign of this complication. The nurse should not instruct a client to omit insulin.

The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan? 1. Maintenance of intact skin 2. Regaining of bladder and bowel control 3. Performance of activities of daily living independently 4. Independent transfer of self to and from the wheelchair

A: Maintenance of intact skin R: A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.

A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (36.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

A: Metabolic acidosis R: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.

When planning care for a client diagnosed with Cushing's syndrome, the nurse should include which intervention to prevent a common complication of this disorder? 1. Monitoring glucose levels 2. Encouraging rigorous exercise 3. Monitoring epinephrine levels 4. Encouraging visits from friends

A: Monitoring glucose levels R: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer. In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Clients experience activity intolerance related to muscle weakness and fatigue; therefore, option 2 is incorrect. Epinephrine levels are not affected. Visitors should be limited because of the client's impaired immune response.

To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal? 1. Fracture bedpan 2. Overhead trapeze 3. Isometric exercises 4. Range-of-motion exercises

A: Overhead trapeze R: The use of an overhead trapeze is extremely helpful for assisting a client with moving about in bed and getting on and off the bedpan. This device has the greatest value for increasing overall bed mobility. A fracture bedpan is useful for reducing discomfort with elimination. Isometric exercises will not increase bed mobility and could be harmful for a client in skeletal traction. Range-of-motion exercises can also be harmful to a client in skeletal traction and should not be initiated unless there are specific prescriptions to do so.

After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate? 1. "What is it about getting out of bed that concerns you?" 2. "If you are afraid of the pain, I can give you medication to help." 3. "If you don't get up and start walking, your recovery will take much longer." 4. "Being dependent on others must be a depressing for an active person like yourself."

A:1. "What is it about getting out of bed that concerns you?" R:Early ambulation during the postoperative period is very important to a client's health and recovery, but many different factors may be contributing to the client's refusal to ambulate as prescribed. Asking an open- ended question that encourages a discussion about getting out of bed is the best option available to allow the nurse to facilitate the client's plan of care. Pain may be a concern for the client, but again, the nurse is making an unfounded assumption. Although it is true that the recovery might be prolonged by not ambulating and the client may be depressed, these statements make assumptions about the reason the client is refusing to comply with the plan of care.

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client indicates an understanding of the nurse's instructions? 1. "I will definitely have to continue taking antithyroid medication after this surgery." 2. "I need to place my hands behind my neck when I have to cough or change positions." 3. "I need to turn my head and neck front, back, and side to side every hour for the first 12 hours after surgery." 4. "I will immediately report to the emergency room if I experience tingling of my toes, fingers, and lips after surgery."

A:2. "I need to place my hands behind my neck when I have to cough or change positions." R: One way of reducing incisional tension is to teach the client how to support the neck when coughing or being repositioned. The removal of the thyroid does not mean that the client will be taking antithyroid medications postoperatively. The client is taught that after thyroidectomy tension needs to be avoided on the suture line because hemorrhage may develop. Likewise, during the postoperative period, the client should avoid any unnecessary movement of the neck; that is why sandbags and pillows are frequently used to support the head and neck. If a client experiences tingling in the fingers, toes, and lips, it is probably a result of injury to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately.