Nursing Health Alterations: Practice test

The assessment of a newly admitted client reveals malnourishment, nausea, distension, and a firm abdomen with ascites. The client has tachycardia and is hypotensive. Which physiological change occurred that resulted in the client's development of ascites?

A decrease in plasma protein to maintain adequate capillary-tissue circulation

Which procedure is shown in the picture?

A thoracentesis

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is an appropriate choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea

Which action would the nurse take in caring for a client after surgical placement of an external fixator on the client's leg?

Perform a neurovascular assessment of the lower extremities

A client is scheduled to have a Tensilon test. Which response to the test would confirm the diagnosis of myasthenia gravis?

Rapid but brief symptomatic improvement

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which is appropriate to include in the client's dietary plan?

Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

Which explanation for the use of Buck traction would the nurse give to the client who has a fractured femur?

Reduces muscle spasms

When a staff nurse is instructed by the charge nurse to give the scheduled warfarin dose to a client whose current INR is 6, which action would the staff nurse take first?

Remind the charge nurse of the INR result

The nurse provides education for a client with cirrhosis of the liver who has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. Which instruction would the nurse include in the teaching?

Report signs of bleeding no matter how slight

How would the nurse describe the clonic phase of a tonic-clonic seizure?

Rhythmic body jerking

Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider?

Right arm weakness

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?

Routines provide stability for clients with neurocognitive disorders

A continuous insulin infusion is started on an adolescent with a blood glucose level of 700 mg/dL (38.9 mmol/L). Which complication would the nurse make a priority of detecting while the adolescent is receiving the infusion?

Hypokalemia

The nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse would be alert for which findings that are consistent with these conditions?

-Ecchymosis -Yellow sclera -Pain in right upper quadrant

Which type(s) of hepatitis most commonly spread by consuming contaminated food and water, or by fecal contamination?

-Hepatitis A -Hepatitis E

Which types of hepatitis develops into a chronic form of the disease?

-Hepatitis B -Hepatitis C -Hepatitis D

The nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joints would the nurse expect the client will report as having been involved first?

-Hips -Knees

The nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is indicative of acute pancreatitis?

Serum lipase

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease would the nurse expect the client to exhibit?

-Butterfly facial rash -Inflammation of the joints

Which factors contribute to development of osteoporosis in female clients?

-Cigarette smoking -Familial predisposition -Inadequate intake of dietary calcium

For which clinical indicators would the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice?

-Dark urine -Yellow skin -Clay-colored stool

Which statement by a client is consistent with a diagnosis of heart failure?

"I have trouble breathing when I climb a flight of stairs"

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis (RA)?

-Development of antinuclear antibodies -Inflammatory disease pattern -Bilateral involvement of metacarpophalangeal joints

A female client asks the nurse whether she should be tested for osteoporosis. Which statements reflect current advice regarding the prevention of osteoporosis?

-"A bone mineral density test is the only way to diagnose osteoporosis" -"Postmenopausal women and all adults over the age of 65 should be tested for osteoporosis"

The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations would the nurse assess in the client?

-Ascites -Pruritus -Jaundice

A child with a seizure disorder has a generalized seizure shortly after admission to the hospital. Which nursing actions are most appropriate?

-Assessing the seizure -Turning the child on the side -Pulling the padded side rails up

The nurse is providing discharge instruction to a client diagnosed with cirrhosis and varices. Which information would the nurse include in the teaching session?

-Avoiding aspirin and aspirin-containing products -Avoid acetaminophen and products containing acetaminophen -Avoiding coughing, sneezing, and straining to have a bowel movement

The nurse is providing care to a client with ascites secondary to liver failure. Which interventions are appropriate to include in the clients care?

-Low-sodium diet -Daily abdominal girth measurements -Daily weights

Which clinical manifestations are found in the client diagnosed with stage 3 of Parkinson disease?

-Mask-like face (begins 2nd stage) -Postural instability -Increased gait disturbances

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy would the nurse assess this client?

-Mental confusion -Flapping hand tremors -Musty, sweet breath odor

Which findings would the nurse expect when assessing a client who is in an early stage of multiple sclerosis?

-Nystagmus (involuntary rhythmic movements of eyes) -Scanning speech -Intention tremors

The nurse provides education for a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions would be included in the teaching plan?

-Screening of blood donors -Maintaining a monogamous sexual relationship

The nurse teaches a client who is concerned about hepatitis transmission routes. Which type of hepatitis spreads more frequently through food?

A

Which client is most at risk for osteoporosis?

A 66-year-old white woman, BMI 18, who is a paralegal

Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction?

Stop the blood transfusion immediately

A client takes acetaminophen routinely. The nurse will advise the client to avoid which substance?

Alcohol

The nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a prescription for neomycin enemas based on which abnormal laboratory test?

Ammonia level

The nurse reviews the laboratory results of a client with acute pancreatitis. Which test is significant in determining the client's response to treatment?

Amylase level

A client admitted with a femur fracture 24 hours ago becomes confused. Which would the nurse do first?

Assess for petechiae

A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which part of the client's assessment?

Assessment of the client's breath

A client is suspected of having myasthenia gravis is scheduled for an edrophonium chloride test. To treat a common complication associated with the test, the nurse will have which medication available?

Atropine

A client has a platelet count of 49,000/mL (40x10^9/L). The nurse would instruct the client to avoid which activity?

Blowing the nose

After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and the endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of which substances?

Fats and carbohydrates

The nurse administers lactulose to a client with cirrhosis of the liver. Which laboratory test change leads the nurse to determine that the lactulose is effective?

Decreased ammonia

A client is treated with lorazepam for status epilepticus. Which effect of lorazepam is the reason it is given?

Depresses the central nervous system (CNS)

Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis?

Difficulty swallowing

Why would lactulose be prescribed for a client with a history of cirrhosis of the liver?

Elevated ammonia levels are lowered

Which signs of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm?

Escalating pain in the fingers

The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" Which effect of alcohol would the nurse include when responding?

It increases enzyme secretion and pancreatic duct pressure that causes back-flow of enzymes into the pancreas

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?

Moderate protein

After an above-the-knee amputation of the right leg, a client reports pain in the right foot. Which reason would the nurse explain to the client for the phantom limb pain?

Nerve endings in the limb are still intact and react to stimuli

When the INR for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take?

Notify the health care provider of the laboratory results

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention?

Observe the client for increasing confusion

Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility?

Occurs with a transfer to new surroundings

A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation?

Optic nerve inflammation

Which assessment technique will the nurse avoid in a client with a suspected hematological disease?

Palpating the abdominal left upper quadrant

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. Which rationale for the treatment would the nurse provide?

To support soft tissue and minimize swelling

When the nurse is caring for a client on the first postoperative day after a lobectomy, which assessment finding requires the most rapid action by the nurse?

Trachea deviates to the nonsurgical side

A client is hospitalized with acute pancreatitis. Which would be included in the client's plan of care?

Use intravenous (IV) fluids

A client admitted to the hospital with a diagnosis of acute pancreatitis. The healthcare provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides which benefit?

Will meet the client's nutritional needs without causing the discomfort precipitated by eating