NUR 202 Test 3 - Immune, Endocrine, Trauma

The ED nurse has the following clients present after an airplane crash. Prioritize the clients in the order in which they should be treated. 75 year old with a history of CHF with a 2 inch laceration to the left forearm 22 year old with a 2 inch laceration with minimal bleeding to the left temple area, slightly confused 14 year old with a history of asthma, wheezing on auscultation, with a 2 inch laceration to the chin 22 year old, 36 weeks pregnant with contractions every 10-15 minutes

1. 14 year old with a history of asthma, wheezing on auscultation, with a 2 inch laceration to the chin 2. 22 year old with a 2 inch laceration with minimal bleeding to the left temple area, slightly confused 3. 22 year old, 36 weeks pregnant with contractions every 10-15 minutes 4. 75 year old with a history of CHF with a 2 inch laceration to the left forearm

A client is experiencing an allergic response. The nurse should do which of the following from first to last? Notify the Physician Obtain IV Access Assess for dyspnea Listen for stridor Call the Rapid response team

1. Listen for stridor 2. Assess for dyspnea 3. Obtain IV Access 4. Call the Rapid response team 5. Notify the Physician

A daily dose of prednisone is prescribed for a client. A nurse reinforces instructions to the client regarding administration of the medication and instructs the client that the best time to take this medication is: 1. At noon 2. At bedtime 3. Early morning 4. Anytime, at the same time, each day

3. Early morning

The reason newborns are protected for the first 6 months of life from bacterial infection is because of the maternal transmission of: A. IgG B. IgA C. IgM D. IgE

A. IgG

One function of cell-mediated immunity is: A. formation of antibodies B. activation of the complement system C. surveillance for malignant cell changes D. opsonization of antigens to allow phagocytosis by neutrophils

C. surveillance for malignant cell changes

A nurse is caring for a client who has SIADH. Which of the following findings should the nurse expect? SELECT ALL that apply a. decreased serum sodium b. urine specific gravity 1.001 c. serum osmolality 230 mOsm/L d. polyuria e. increased thirst

a. decreased serum sodium c. serum osmolality 230 mOsm/L

A nurse provides home care instructions to a client with Lupus and tells the client about methods to manage fatigue. Which statement by the client indicates the need for further teaching? a. "I should take hot baths because they are relaxing." b. "I should sit whenever possible to conserve my energy." c. "I should avoid long periods of rest because it causes joint stiffness." d. "I should do some exercises, such as walking, when I am not fatigued."

a. "I should take hot baths because they are relaxing."

You are doing patient teaching about Addison's Disease. The patient's son asks you how long his father will have to take corticosteroids? What is your best response? a. "Your father will have to take corticosteroids for the rest of his life." b. "He can stop taking them when he learns to better manage his stress." c. "He won't need them if his activities are indoors and he stays out of the sun." d. "He will only need corticosteroids when he has a Dentist or Doctor appointment.

a. "Your father will have to take corticosteroids for the rest of his life." Addison's Disease requires a patient to take steroids for the rest of their lives. Managing the disease is very important because physical and emotional stress could increase the need for more steroids. Staying indoors or out of the sun will not affect the disease. Medical and Dental appointments do not require special doses.

The nurse in the Emergency department reports that there is a possibility of having had direct contact with blood of a client who is suspected of having HIV/AIDS. The nurse requests that the client have a blood test. Consent for HIV testing can only be completed when the following circumstances are present. SELECT ALL that apply. a. A health care provider has been exposed to the clients blood or body fluids b. Testing is prescribed by a physician under emergency conditions c. Testing is prescribed by the court, based on evidence that a client poses a threat to others d. Testing is done on blood collected anonymously in an epidologic survey e. When a health care provider who is taking care of a client suspected of having HIV/AIDS requests a blood test

a. A health care provider has been exposed to the clients blood or body fluids b. Testing is prescribed by a physician under emergency conditions c. Testing is prescribed by the court, based on evidence that a client poses a threat to others d. Testing is done on blood collected anonymously in an epidologic survey

Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? SELECT ALL that apply a. BP 80/50 b. HR 54 c. glucose 63 d. sodium 148 e. potassium 6.3 f. temperature 101.1

a. BP 80/50 c. glucose 63 e. potassium 6.3 f. temperature 101.1

A client is recovering from an infected abdominal wound. Which of the following foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? a. Chicken and orange slices b. Cheeseburger and mashed potatoes c. Cheese omelet and bacon d. Gelatin salad and tea

a. Chicken and orange slices

The nurse is alerted to possible anaphylactic shock immediately after a patient has received IM penicillin by the development of a. edema and itching at the injection site b. sneezing and itching of the nose and eyes c. a wheal-and-flare reaction at the injection site d. chest tightness and production of thick sputum

a. edema and itching at the injection site

Which foods should be included in patient education for a patient suffering from hypoparathyroidism from lack of PTH? a. Dark green leafy vegetables b. Spinach, yogurt and bananas c. Whole grain bread, milk and liver d. Yellow beans, rhubarb and fish

a. Dark green leafy vegetables Hypoparathyroidism from lack of PTH produces chronic hypocalcemia. Foods to include in teaching should be high in calcium like dark green leafy vegetables, soybeans and tofu.

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a: a. Micron mesh filter b. Nonfiltered blood administration set c. Special leukocyte-poor filter d. Microdrip administration set

a. Micron mesh filter

Which of the following findings should lead the nurse to suspect that a client who had a cesarean delivery 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider? SELECT ALL that apply. a. Petechiae on the arm where the blood pressure was taken b. Heart rate of 126 c. Abdominal incision dressing with bright red drainage d. Platelet count of 80,000 e. U/O of 350 ml in the past 8 hours f. Temperature of 98.4

a. Petechiae on the arm where the blood pressure was taken b. Heart rate of 126 c. Abdominal incision dressing with bright red drainage d. Platelet count of 80,000

A client experienced a pneumothorax after the placement of a CVP line. Which of the following assessments supports a medical diagnosis of a pneumothorax? a. Sudden, sharp pain on the affected side b. tracheal deviation toward the affected side c. Bradypnea and elevated BP d. Presence of crackles and wheezes

a. Sudden, sharp pain on the affected side

The nurse should teach the client with neutropenia and the family to avoid which of the following? a. Using suppositories or enemas b. Using a HEPA filter mask c. Performing peri care after each bowel movement d. Performing oral care after every meal

a. Using suppositories or enemas

The nurse is preparing discharge teaching for a woman newly diagnosed with SLE. What will be important for the nurse to include in the teaching plan? SELECT ALL that apply a. Wear sunscreen and protective clothing in direct sunlight b. Avoid NSAIDs to prevent bleeding episodes c. Plan activities that encourage range of motion in extremities. d. Advise the client that pregnancy is contraindicated e. Observe fingertips for changes in circulation f. Help the client prioritize self-care activity.

a. Wear sunscreen and protective clothing in direct sunlight c. Plan activities that encourage range of motion in extremities. e. Observe fingertips for changes in circulation f. Help the client prioritize self-care activity.

A client with hyperthyroidism has been given methimazole/Tapazole. Which nursing considerations are associated with this medication? SELECT ALL that apply a. administer methimazole with food b. place the client on a low calorie, low protein diet c. assess the client for unexplained bruising or bleeding d. instruct the client to report side effects such as sore throat, fever or headaches e. use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration

a. administer methimazole with food c. assess the client for unexplained bruising or bleeding d. instruct the client to report side effects such as sore throat, fever or headaches

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SELECT ALL that apply a. encourage the client to cough every 2 hours b. check for continuous bubbling in the suction chamber c. strip the drainage tubing every 4 hours d. clamp the tube once a day e. obtain a chest x ray

a. encourage the client to cough every 2 hours b. check for continuous bubbling in the suction chamber e. obtain a chest x ray

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient exhibits which clinical manifestations? a. facial muscle spasms and laryngospasms b. tingling in the hands and around the mouth c. decreased muscle tone and muscle weakness d. shortened QT interval on EKG

a. facial muscle spasms and laryngospasms

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? SELECT ALL that apply a. fever b. nausea c. lethargy d. tremors e. confusion f. bradycardia

a. fever b. nausea d. tremors e. confusion

After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching regarding the need for lifelong hormone therapy.

a. frequent monitoring of serum and urine osmolarity.

A nurse is planning care for a client with Cushing's Disease. The nurse should recognize that clients who have Cushing's are at increased risk for which of the following? SELECT ALL that apply a. infection b. gastric ulcer c. renal calculi d. bone fractures e. dysphagia

a. infection b. gastric ulcer d. bone fractures

The nurse is monitoring a client receiving Synthroid for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? SELECT ALL that apply a. insomnia b. weight loss c. bradycardia d. constipation e. mild heat intolerance

a. insomnia b. weight loss e. mild heat intolerance

A nurse in a provider's office is planning care for a patient with a new diagnosis of Grave's Disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? SELECT ALL that apply a. monitor CBC b. monitor T3 c. instruct the client to increase intake of shellfish d. advise the client to take the medication at the same time every day e. inform the client that an adverse effect of this medication is iodine toxicity

a. monitor CBC b. monitor T3 d. advise the client to take the medication at the same time every day

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which signs and symptoms would represent the expected electrolyte imbalance? SELECT ALL that apply a. nausea and vomiting b. neurologic irritability c. lethargy and weakness d. increasing urine output e. hyperactive bowel sounds

a. nausea and vomiting c. lethargy and weakness d. increasing urine output

A nurse is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? SELECT ALL that apply a. observe cardiac monitor for dysrhythmias b. observe for evidence of UTI c. initiate IV fluids using NS d. administer levothyroxine IV bolus e. provide warmth with a heating pad

a. observe cardiac monitor for dysrhythmias b. observe for evidence of UTI c. initiate IV fluids using NS d. administer levothyroxine IV bolus

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? SELECT ALL that apply a. oxygen b. sterile water c. enclosed hemostat clamps d. indwelling urinary catheter e. occlusive dressing

a. oxygen b. sterile water c. enclosed hemostat clamps e. occlusive dressing

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? SELECT ALL that apply a. perinatal exposure b. pregnancy c. monogamous sex partner d. older adult woman e. occupational exposure

a. perinatal exposure d. older adult woman e. occupational exposure

Assessment findings suggestive of peritonitis include... SELECT ALL that apply a. rebound tenderness b. a soft, distended abdomen c. dull, intermittent abdominal pain d. shallow respirations with bradypnea e. observing that the patient is lying still

a. rebound tenderness e. observing that the patient is lying still

A patient has a serum sodium level of 152. The normal hormonal response to this situation is a. release of ADH b. release of ACTH c. secretion of aldosterone d. secretion of corticotropin-releasing hormone

a. release of ADH

A nurse is reviewing labs for a client who has Cushing's. Which of the following findings should the nurse expect for this client? SELECT ALL that apply a. sodium 130 b. potassium 6.1 c. calcium 11.6 d. BUN 28 e. fasting blood glucose 148

a. sodium 130 b. potassium 6.1 c. calcium 11.6 d. BUN 28

A nurse is reviewing labs for a client who has Cushing's. Which of the following findings should the nurse expect for this client? SELECT ALL that apply a. sodium 150 b. potassium 3.3 c. calcium 8.0 d. lymphocyte count 35% e. fasting glucose 145

a. sodium 150 b. potassium 3.3 c. calcium 8.0 e. fasting glucose 145

A nurse is assessing a client following a GSW to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? SELECT ALL that apply a. tachypnea b. deviation of the trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain

a. tachypnea b. deviation of the trachea e. pleuritic pain

Which statements accurately describe HIV infection? SELECT ALL that apply a. untreated HIV infection has a predictable pattern of progression b. late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS) c. untreated HIV infection can remain in the early chronic stage for a decade or more d. untreated HIV infection usually remains in the early chronic stage for 1 year or less e. opportunistic diseases occur more often when the CD4 cell count is high and the viral load is low

a. untreated HIV infection has a predictable pattern of progression b. late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS) c. untreated HIV infection can remain in the early chronic stage for a decade or more

Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission? a. use sterile equipment to inject drugs b. clean equipment used to inject drugs c. taking lamivudine (Epivir) during pregnancy d. using latex or polyurethane barriers to cover genitalia during sexual contact

a. use sterile equipment to inject drugs

At the beginning of a shift, a nurse is assessing a client who has Cushing's. Which of the following findings is the priority? a. weight gain b. fatigue c. fragile skin d. joint pain

a. weight gain

The nurse is providing discharge instructions to a client who has Cushing's. Which client statement indicated that instructions related to dietary management are understood? a. "I will need to limit my protein intake." b. "I should eat foods that have a lot of potassium in them." c. "I am fortunate that I can eat all the salty foods I want." d. "I am fortunate that I do not need to follow any special diet."

b. "I should eat foods that have a lot of potassium in them."

Which statements about metabolic side effects of antiretroviral (ART) therapy are true? SELECT ALL that apply a. these are annoying symptoms that are ultimately harmless b. ART related body changes include fat redistribution and peripheral wasting c. lipid abnormalities include increases in triglycerides and decreases in high density cholesterol d. insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol e. compared to uninfected people, insulin resistance and hyperlipidemia are more difficult to treat in HIV infected patients

b. ART related body changes include fat redistribution and peripheral wasting c. lipid abnormalities include increases in triglycerides and decreases in high density cholesterol d. insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol

Immediately following an automobile accident, a 21 year old client has severe pain in the left chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the first priority for care for this patient? a. Reduce the client's anxiety about the other people in the car b. Apply nasal cannula to maintain adequate oxygenation c. Connect to cardiac monitor to assess cause of chest pain d. Start IVF to maintain circulating blood volume

b. Apply nasal cannula to maintain adequate oxygenation

The nurse is assessing a client in irreversible shock. Which of the following is an expected finding? a. Increased alertness b. Circulatory collapse c. Hypertension d. Diuresis

b. Circulatory collapse

A patient has been diagnosed with an iodine allergy. In addition to teaching about what foods to avoid that are high in iodine, what symptoms should you teach the paitent about that are indicative of an endocrine condition related to low iodine intake? Select one: a. Diarrhea, weight loss and blurred vision b. Constipation, weight gain, and intolerance to cold c. Fatigue, dry skin and increased blood pressure. d. Anorexia, dyspnea and weight loss.

b. Constipation, weight gain, and intolerance to cold. The thyroid gland needs iodine to produce thyroid hormone. Without it, the patient can have low thyroid production and exhibit symptoms of hypothyroidism which would include constipation, weight gain, weakness, intolerance to cold, dyspnea, fragile hair.

You have a patient with SIADH. Which fluid and electrolyte imbalance will you assesss this patient for? a. Increased osmolality of the plasma b. Decreased serum sodium level c. Increased urine output d. Decreased blood pressure

b. Decreased serum sodium level

The nurse would recognize which clinical manifestation as suggestive of sepsis? a. Sudden diuresis unrelated to drug therapy b. Hyperglycemia in the absence of diabetes c. Respiratory rate of seven breaths per minute d. Bradycardia with sudden increase in blood pressure

b. Hyperglycemia in the absence of diabetes

The nurse is reviewing with a certified nursing assistant (CNA) the care for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS) and has developed P. jiroveci pneumonia (PJP, PCP). Which of the following precautions would the nurse review with the CNA? a. Strict handwashing b. Airborne precautions c. Contact precautions d. Standard precautions

d. Standard precautions

The physician orders IV cefazolin (Kefzol) 1g for a client. In preparing to administer the Kefzol, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take? a. Continue to prepare the Kefzol as prescribed b. Notify the physician of the client's allergy to penicillin c. Administer the Kefzol, staying at the client's bedside during the infusion d. Call the Pharmacist to verify that the Kefzol should be administered as prescribed

b. Notify the physician of the client's allergy to penicillin

A patient has had a thyroidectomy. What complication will you watch for related to possible damage to the parathyroid glands? a. Hypertension b. Numbness around the mouth c. Polyuria d. Muscle weakness

b. Numbness around the mouth The correct answer is numbness which is an early sign of hypocalcemia.

A nurse in the ED is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? SELECT ALL that apply a. bradycardia b. cyanosis c. hypotension d. dyspnea e. parodoxic chest movement

b. cyanosis c. hypotension d. dyspnea e. parodoxic chest movement

A nurse is reviewing lab results for a client who is being evaluated for secondary hypothyroidism. Which of the following lab findings is expected for a client who has this condition? a. elevated T4 b. decreased T3 c. elevated TSH d. decreased serum cholesterol

b. decreased T3

An abnormal finding by the nurse during an endocrine assessment would be: (select all that apply) a. blood pressure of 100/70 mm Hg b. excessive facial hair on a woman c. soft, formed stool every other day d. 3-lb weight gain over last 6 months e. hyperpigmented coloration in the lower legs

b. excessive facial hair on a woman e. hyperpigmented coloration in the lower legs

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SELECT ALL that apply a. continuous bubbling in water seal chamber b. gentle constant bubbling in suction chamber c. rise and fall in the level of water in the water seal chamber with inspiration and expiration d. exposed sutures without dressing e. drainage system upright at chest level

b. gentle constant bubbling in suction chamber c. rise and fall in the level of water in the water seal chamber with inspiration and expiration

The patient with Lupus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should be included in the plan of care? SELECT ALL that apply a. obtain weekly weights b. limit fluids to 1000 mL/day c. monitor for signs of hypernatremia d. administration of diuretics as ordered e. minimize turning and ROM f. keep the HOB at 10 degrees elevation or less

b. limit fluids to 1000 mL/day d. administration of diuretics as ordered f. keep the HOB at 10 degrees elevation or less

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching? SELECT ALL that apply a. weight gain is expected while taking this medication b. medication should not be discontinued without the advice of the provider c. follow up TSH levels should be obtained d. take the medication on an empty stomach e. use fiber laxatives for constipation

b. medication should not be discontinued without the advice of the provider c. follow up TSH levels should be obtained d. take the medication on an empty stomach

A nurse is collecting an admission history on a female client who has hypothyroidism. Which of the following findings should the nurse expect? SELECT ALL that apply a. diarrhea b. menorrhagia c. dry skin d. increased libido e. hoarseness

b. menorrhagia c. dry skin e. hoarseness

Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

b. monitoring blood glucose levels. e. protecting patient from exposure to infection.

A nurse is providing medication teaching for a client with Addison's Disease taking hydrocortisone. Which of the following instructions should the nurse include? SELECT ALL that apply a. take the medication on an empty stomach b. notify the MD of any illness or stress c. report any manifestations of weakness or dizziness d. do not discontinue the medication suddenly e. eat a low sodium diet

b. notify the MD of any illness or stress c. report any manifestations of weakness or dizziness d. do not discontinue the medication suddenly

A nurse is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse anticipate? SELECT ALL that apply a. IV therapy with 0.45% NS b. regular insulin c. hydrocortisone sodium succinate d. sodium polystyrene sulfonate e. furosemide

b. regular insulin c. hydrocortisone sodium succinate d. sodium polystyrene sulfonate e. furosemide

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes and her cervix is 3/100/-1. She is crying uncontrollably and states her pain is constant and severe rating it at 10/10. The priority nursing action by the nurse is to: a. Reassure the woman and assist with establishing a focal point and breathing techniques b. Reassess intensity and determine if she would like an epidural c. Evaluate for signs of potential abruption d. Assess for signs of a prolapsed umbilical cord

c. Evaluate for signs of potential abruption

Which nursing assessment finding is commonly associated with a diagnosis of systemic lupus erythematosus (SLE)? : a. Excitability, diarrhea, vomiting b. High fever, measles-like rash on limbs, weight gain c. Joint pain, rash over the bridge of the nose, photosensitivity d. Weight loss, adventitious breath sounds, and epigastric pain

c. Joint pain, rash over the bridge of the nose, photosensitivity

Your patient's care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyperglycemic syndrome secondary to severe hyperglycemia. Which lab will reflect a positive outcome? Select one: a. Glucose b. Sodium c. Osmolality d. Potassium

c. Osmolality Severe hyperglycemia produces severe osmotic diuresis with loss of NA, K, Ph and profound dehydration. Consequently, hyperosmolality occurs. Normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates hyperglycemia is less but not the fluid volume deficit. Na and K values should increase not decrease with treatment.

Which of the following findings should the nurse note in the client who is in the compensatory stage of shock? a. Decreased urinary output b. Significant hypotension c. Tachycardia d. Mental confusion

c. Tachycardia

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels b. restrict fluid and sodium intake c. administer potassium-sparing diuretics d. advise the patient to make postural changes slowly

c. administer potassium-sparing diuretics

Which types of isolation precautions are appropriate for a patient with TB? SELECT ALL that apply a. contact precautions b. droplet precautions c. airborne precautions d. standard precautions e. neutropenic precautions

c. airborne precautions d. standard precautions

PRBC's have been prescribed for a client with low HGB and HCT levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 orally. Which action should the nurse take? a. begin the transfusion as prescribed b. administer an antihistamine and begin the transfusion c. delay hanging the blood and notify the MD d. administer 2 tablets of acetaminophen and begin the transfusion

c. delay hanging the blood and notify the MD

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which of the following are expected assessment findings? SELECT ALL that apply a. excessive bubbling in water seal chamber b. vigorous bubbling in suction control chamber c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

A nurse is assessing a client who is 12 hours post thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis? SELECT ALL that apply a. bradycardia b. hypothermia c. dyspnea d. abdominal pain e. mental confusion

c. dyspnea d. abdominal pain e. mental confusion

A nurse is providing teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? SELECT ALL that apply a. brush your teeth after every meal or snack b. avoid bending at the knees c. eat a high fiber diet d. notify the MD of any sweet tasting drainage e. notify the MD of any diminished sense of smell

c. eat a high fiber diet d. notify the MD of any sweet tasting drainage

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? SELECT ALL that apply a. tremors b. weight loss c. feeling cold d. loss of body hair e. persistent lethargy f. puffiness of the face

c. feeling cold d. loss of body hair e. persistent lethargy f. puffiness of the face

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema b. muscle spasticity and hypertension c. low urine output and hyponatremia d. weight gain and decreased glomerular filtration rate

c. low urine output and hyponatremia

The nurse provides instructions to a client takin Synthroid. The nurse should tell the client to take the medication at which time? a. with food b. at lunchtime c. on an empty stomach d. at bedtime with a snack

c. on an empty stomach

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? a. a coagulation time of 5 minutes b. a urinary output of 50 mL/hr c. a BUN of 20 d. a heart rate that is 90 and irregular

d. a heart rate that is 90 and irregular

The nurse is providing teaching for a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicated understanding of the teaching? a. "I can drink up to 2 quarts of fluid a day" b. "I will need to use insulin to control my blood glucose levels" c. "I should expect to gain weight during this illness" d. "Muscle weakness is a symptom of diabetes insipidus"

d. "Muscle weakness is a symptom of diabetes insipidus"

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? a. "Notify the MD if you experience weakness" b. "You should be able to return to work in 1 week" c. "You need to wear a mask when in crowded areas" d. "Notify the MD if you experience a productive cough"

d. "Notify the MD if you experience a productive cough"

The nurse is following up after therapy plans were discussed by the physician with the client who is considering antiviral therapy for the treatment after confirmation of a positive status for the human immunodeficiency virus (HIV) test. The client asks the nurse how long the therapy will last. The nurse bases a response on the understanding that therapy lasts: a. Only 1 year b. A minimum of 5 years c. No longer than 10 years d. A lifetime

d. A lifetime

A client is experiencing difficulty breathing, periorbital swelling, flushing, and itching. He had a diagnostic test in which an iodine-based dye was used about an hour earlier. What medication will the nurse anticipate administering immediately? a. A bronchodilator such as aminophylline (Theophylline) b. A corticosteroid such as dexamethasone (Decadron) c. An antihistamine such as diphenhydramine (Benadryl) d. An adrenergic agonist such as epinephrine (Adrenalin)

d. An adrenergic agonist such as epinephrine (Adrenalin)

A child has rubeola. What type of immunity to rubeola will this child have after his recovery? a. Artificially acquired active immunity b. Artificially acquired passive immunity c. Naturally acquired passive immunity d. Naturally acquired active immunity

d. Naturally acquired active immunity

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find: a. leukopenia b. RBC abnormalities c. decreased hemoglobin d. increased platelet count

d. increased platelet count After a splenectomy, expect elevated WBC, PLT and RBC

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

d. laryngospasms and tingling in the hands and feet.

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

d. level of consciousness, urine output, and skin color and temperature.

A patient has a SCI at T4. Vital signs include falling BP with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia b. an absolute hypovolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation

d. neurogenic shock from massive vasodilation