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A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication does the nurse expect the healthcare provider to prescribe to relieve the client's physiologic responses to this disease? 1. Carbidopa-levodopa 2.Isocarboxazid 3.Selegiline 4. Dopamine 5. Pyridoxine
Correct Answer: 1 Rationale: Levodopa crosses the blood-brain barrier and converts to dopamine, a substance depleted in Parkinson disease. Isocarboxazid is a monoamine oxidase inhibitor used for the treatment of psychological symptoms associated with severe depression, not physiologic symptoms of Parkinson disease. Dopamine is not given because it does not cross the blood-brain barrier. Pyridoxine can reverse the effects of some antiparkinsonian medications and is contraindicated.
A nurse is assessing a school-aged child with cystic fibrosis. What complication of frequent stools and tenacious mucus does the nurse anticipate? 1. Anal fissures 2. Rectal prolapse 3. Intussusception 4. Meconium ileus
Correct Answer: 2, good ol' rectal prolapse Rationale: Rectal prolapse, a common gastrointestinal complication of cystic fibrosis, results from wasting of perirectal supporting tissues because of malnutrition. Anal fissures usually do not occur with cystic fibrosis. Intussusception is not associated with cystic fibrosis. Meconium ileus is associated with cystic fibrosis in newborns; it prevents the passage of meconium.
The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 1. Dehydration 2. Skin breakdown 3. Electrolyte Imbalance 4. UTI
Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.
A health care provider prescribes cholestyramine, an anion exchange resin, to treat a client's persistent diarrhea. What vitamin does the nurse anticipate may become deficient because cholestyramine reduces the absorption of fat? 1.Retinol (Vitamin A) 2.Riboflavin (Vitamin B2) 3. Thiamine (Vitamin B12) 4.Pyridoxine (Vitamin B6)
Correct Answer, 1, Retinol (Vitamin A) Rationale: Cholestyramine is a fat-binding agent; it binds with and interferes with all the fat-soluble vitamins (A, D, E, and K). Thiamine is not a fat-soluble vitamin and is unaffected. Riboflavin is not a fat-soluble vitamin and is unaffected. Vitamin B6 is not a fat-soluble vitamin and is unaffected.
A client with osteoarthritis is admitted to the hospital for evaluation of a possible hip replacement. To prevent flexion contractures, the nurse recommends that, when in bed, the client should lie in the supine or prone position. The client voices hesitation, stating that these positions are uncomfortable for the knees and hips. What action should the nurse take? 1. Encourage the client to maintain exstention for periods of time 2. Allow the client to lie in whatever position is most comfortable 3. Insert a pillow under the client's knees to relieve discomfort 4. Place the client in semi-Fowler's position most of the time
Correct Answer: 1 Rationale: Flexion contractures of the hips and knees can develop unless some periods of full extension are maintained. The most comfortable position that usually is assumed is one of flexion, which leads to contractures and should be avoided. Placing a pillow under the knees can cause flexion contractures of the hips and knees. Remaining in the semi-Fowler's position can cause flexion contractures of the hips.
The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning? 1. Banana 2. Carrots 3. Yogurt 4. Tomato juice
Correct Answer: 1, Banana Rationale: A medium banana contains only 1 mg of sodium. All the rest are higher than a banana. Carrots are low in sodium, but ¼ cup contains 10 mg. Yogurt contains over 80 mg, while tomato juice is the highest.
A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? 1. Serum sodium 2. Urinary output 3. Hematocrit level 4. Serum potassium
Correct Answer: 2 Rationale: As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.
After gastrointestinal surgery, a client's condition improves, and a regular diet is prescribed. Which food, included on a regular diet, should the nurse encourage the client to consume to decrease discomfort? 1. Fresh fruit 2. Baked fish 3. Bran cereal 4. Whole milk
Correct Answer: 2 Rationale: Baked fish is a low-residue, low-fat, high-protein, and non-gas-producing food that usually is tolerated well. Fresh fruit has fiber that irritates the gastrointestinal tract. Bran cereal has fiber that irritates the gastrointestinal tract. Whole milk irritates the gastrointestinal tract and stimulates mucus production.
A nurse is planning care to prevent deformities and contractures in a client with burns. When will the nurse begin range-of-motion (ROM) exercises? 1. When pain has lessened 2. When vital signs are stable 3. When skin grafts have healed 4. When emotional status stabilizes
Correct Answer: 2 Rationale: ROM exercises should be instituted as soon as it will not compromise the individual's cardiopulmonary status. Pain will continue for some time, and if ROM exercises are delayed until it subsides, contractures will develop. If ROM exercises are delayed until skin grafts heal, contractures will develop. Pain and inability to cope may be prolonged; if ROM exercises are delayed, contractures will develop.
A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1. Polyuria 2. Weakness 3.Hypertension 4.Truncal obesity 5.Intermittent tonic spasms
Correct Answer: 2, 3, 4 Rationale: Weakness occurs in response to the excessive catabolism of proteins and resulting loss of muscle mass. Hypertension occurs in response to excessive cortisol that causes an increase in circulating volume or an arteriole response to circulating catecholamines. Truncal obesity is caused by abnormal fat metabolism and deposition of fat in the mesenteric bed. Polyuria, excessive urination, occurs with hyperglycemia and is associated with diabetes mellitus. Intermittent tonic spasms of the extremities are associated with tetany, a neuromuscular manifestation, because of a decrease in ionized calcium occurring in hypoparathyroidism, not Cushing syndrome.
A nurse is assessing a client for dehydration. The client has had diarrhea and vomiting for 48 hours. Which assessment findings alert the nurse that the client is dehydrated? Select all that apply. 1. Protruding eyeballs 2. Postural hypotension 3. The client reporting eating 3 meals a day 4. The skin on the client's forehead remains tented after pinching 5. Within 4 days the client gained 2 pounds of weight
Correct Answer: 2, 4 Rationale: Postural hypotension is an indicator of dehydration. To determine dehydration in the adult, the nurse should test for decreased skin turgor. To assess for dehydration, pinch the skin over a bone with little or no underlying fat, such as the sternum or forehead. If the skin remains tented after it is released, the client is dehydrated. The eyeballs may be sunken, not protruding, in the presence of dehydration. The client reporting eating three meals a day does not indicate dehydration. A weight gain of two pounds (0.9 kilograms) does not indicate dehydration but does indicate fluid retention/excess.
A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? Select all that apply. 1. Rate of pulse 2. Skin color 3. Presence of edema 4. Movement of the hand 5. Sensations in the extremity
Correct Answer: 2, 4, 5 Rationale: Pale or dusky skin tone may indicate impaired circulation to the extremity. The ability to move the area distal to surgery is indicative of adequate blood flow and integrity of nerves. Paresthesias may indicate lack of vascular or nerve integrity. Appropriate perception of sensations indicates functioning of nerves and is included in the neurovascular assessment. The quality of the pulse, not its rate, should be monitored. If it is weak and thready, it may indicate impaired circulation to the extremity. It is too soon after surgery for edema to develop, and its evaluation is not a neurovascular assessment
The nurse is caring for a client 4 hours after the client's hip replacement surgery. What should the nurse do when assisting the client out of bed? 1. Tell the client that both legs must have equal weight bearing. 2.Advise the client that the legs must continually be kept wide apart 3.Sit the client in a straight-back chair so that the hips are kept flexed 4.Transfer the client using a mechanical lift, because weight bearing on the leg is not allowed
Correct Answer: 2, Advise the client that the legs must continually be kept apart Rationale: Abduction keeps the prosthesis firmly in place; adduction of the extremity may cause the prosthesis to dislocate. Only partial weight bearing on the affected leg is indicated initially. Sitting flexes the hips to 90 degrees; this is contraindicated initially, because it can cause the prosthesis to dislocate. Full weight bearing on the unaffected leg and partial weight bearing on the affected leg generally are permitted on the second or third postoperative day.
A client develops epistaxis and seeks treatment at a first aid station. Which action should the nurse take? 1. tilt the head backwards 2. pack the nose with tissue 3. apply direct lateral pressure to the nose 4. instruct the client to blow the nose gently
Correct Answer: 3 Rationale: Apply direct lateral pressure to the nose for 10 minutes and apply ice or cool compresses to the nose and face if possible. Tilting the head back will cause the blood to be swallowed, which can result in vomiting and aspiration. Packing the bleeding nostril with tissue may cause further damage if done too firmly; some of the tissue may be left in the nose, causing an additional problem. Gauze or nasal tampons are used for packing. Blowing the nose can prevent clotting, which can result in prolonged bleeding.
A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? 1. It equals the expected urinary output for the next 24 hours 2. It will prevent the development of pneumonia and a high fever. 3.It will compensate for both insensible and expected output over the next 24 hours 4. It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias
Correct Answer: 3 Rationale: Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.
The nurse is assessing a client who reports frequent urination. Which inquiry made by the nurse will help determine diabetes insipidus? 1. "Do you have history of cancer?" 2.Are you on fluoroquinolone therapy? 3."Are you on lithium carbonate therapy?" 4.Do you have a history of lymphoma?"
Correct Answer: 3, "Are you on fluroquinolone therapy?" Rationale: Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Therefore enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination. Inquiry about history of cancer helps in assessing syndrome of inappropriate antidiuretic hormone (SIADH) because some cancer therapy drugs result in SIADH. Treatment with fluoroquinolone antibiotics also can result in SIADH. Hodgkin's and Non-Hodgkin's lymphoma are causes of SIADH.
A nurse anticipates that dialysis will be necessary for a 12-year-old child with chronic kidney disease when the child begins to exhibit which symptom? 1.Hypotension 2.Hypokalemia 3.Hypervolemia 4.Hypercalcemia
Correct Answer: 3, Hypervolemia Rationale: Hypervolemia results when the kidneys have failed and are no longer able to maintain homeostasis, the blood pressure is high, and cardiac overload is imminent. Hypertension, not hypotension, is present when kidney failure occurs. Hyperkalemia, not hypokalemia, occurs with kidney failure. Hypocalcemia, not hypercalcemia, is present when kidney failure occurs.
A 5-week-old infant is admitted to the hospital with a tentative diagnosis of a congenital heart defect. The infant tires easily and has difficulty breathing and feeding. In what position should the nurse place this infant? 1. Supine, with the knees flexed 2.Orthopneic, with pillows for support 3. Side-lying, with the upper body elevated 4. Prone, with the head supported by pillows
Correct Answer: 3, Side-lying, with the upper body elevated Rationale: In the side-lying position with the head and chest elevated, gravity promotes respiratory excursion; alternating side-lying positions allows pulmonary drainage and expansion. Placing the infant in an infant seat helps maintain these positions. The supine position causes the abdominal viscera to put pressure on the diaphragm, thereby impeding lung expansion. The orthopneic position is difficult to maintain in a 5-week-old infant; in addition, this position will not promote rest. The prone position will make it difficult for the lungs to expand, causing difficulty breathing.
The nurse is teaching a diabetic client about the advantages of using an insulin pump. What information should the nurse include? Select all that apply. 1. it prevents ketoacidosis 2. it helps cause weight loss 3. it can improve A1C levels 4. An insulin pump costs less than subcutaneous injections 5. Clients can exercise without eating more carbohydrates
Correct Answer: 3,5 Rationale: Maintaining a consistent acceptable blood glucose level will improve A1C results. Because insulin is administered only as needed, the client will be able to exercise without having to increase the carbohydrate intake. Ketoacidosis may occur if the catheter becomes dislodged and the client does not receive insulin for hours. Insulin pumps can cause weight gain, not loss. An insulin pump is more expensive than subcutaneous insulin injections.
A nurse plans to take the temperature of a 4-year-old child with a diagnosis of leukemia who has a fever. Which thermometers with the most accurate results can the nurse use safely for this child? Select all that apply. 1. Digital, rectal 2. Electronic, oral 3. Infrared, tympanic 4. Sensor, ear-based 5. Chemical dot, axilla
Correct Answer: 3,5 Rationale: The infrared thermometer can be used on the tympanic membrane; it is safe to use for a child with leukemia. The chemical dot or liquid crystal skin contact thermometer is a flexible, one-use, disposable thermometer. It can be used to take oral or axillary temperatures and is safe for use in a child with leukemia. Rectal temperature taking is contraindicated in children with leukemia because it may result in trauma to the rectal mucosa. Also, the use of a rectal probe may be perceived as an intrusive procedure by a 4-year-old. Most digital thermometers can be used to take oral, axillary, or rectal temperatures. An oral temperature with an electronic thermometer is not safe or accurate for a 4-year-old; it is considered safe for a child who is at least 5 years old. The ear-based sensor thermometer is used in ambulatory settings; its reliability is a matter of some controversy.
A client underwent an external ear assessment and is diagnosed with hard nodules on the pinna. Which assessment finding indicates tophi? 1. Ulcerative lesions at the site 2. Crusted indurated lesions at the site 3. Decreased calcium levels in the blood 4. Increased uric acid levels in the blood
Correct Answer: 4 Rationale: Chronic gout is characterized by hard, irregular, painless nodules on the pinna or external ear known as tophi that form due to the accumulation of uric acid crystals. This condition is diagnosed by increased levels of uric acid in the blood. Squamous cell carcinoma is diagnosed by the appearance of small, crusted, ulcerated, or indurated lesions on the pinna that fail to heal. Decreased calcium levels in the blood are indications of osteoporosis.
A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? 1.Disintegration of the myelin sheath 2.Breakdown of upper and lower neurons 3.Reduced acetylcholine receptors at synapses 4.Degeneration of the neurons of the basal ganglia
Correct Answer: 4, Degeneration of the neurons of the basal ganglia Rationale: Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.
The nurse finds that a client has dysuria, hesitancy, urinary urgency, and leaking. The laboratory reports of the client reveal serum PSA levels of 5 ng/mL and elevated prostatic acid phosphatase (PAP) levels. Which disease condition does the nurse suspect? 1. Orchitis 2. Hydrocele 3. Prostatitis 4. Prostate Cancer
Correct Answer: 4, Prostate Cancer Rationale: Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling. PSA is a blood test used to confirm prostate cancer. An elevated level of prostatic isoenzyme of serum acid phosphatase (PAP) is another indicator of prostate cancer. The normal range of PSA levels is 0-4 ng/mL. Therefore, the client has elevated PSA levels. Acute inflammation of the testis indicates orchitis, which is characterized by painful, tender, and swollen testis. A hydrocele is nontender, scrotal swelling caused by an accumulation of serous fluid in the scrotum. PSA levels are not elevated with a hydrocele. Prostatitis is a condition that involves inflammation of the prostate gland and is characterized by fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine. Increased PSA levels also indicate prostatitis, but the symptoms such as hesitancy and dribbling, and elevated levels of PAP are not associated with prostatitis.
A client comes to the clinic reporting weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. Which question is most appropriate for the nurse to ask initially? 1. "Are you sexually active?" 2. "Do you have a sore throat?" 3.
Correct Answer Rationale : The length of time a low-grade fever is present, together with a history of night sweats and other physical findings, is valuable information in assisting the nurse with care planning and helping the primary healthcare provider determine a diagnosis. Sexual activity is not immediately relevant to the presenting signs and symptoms; more should be explored about the temperature itself before investigating causes of the temperature. Whether the client had a sore throat or exposure to an infection is not immediately relevant to the presenting signs and symptoms; more should be explored about the temperature increase itself before investigating its causes.