Seminar

The physician orders chest physiotherapy on your patient with cystic fibrosis. This is best performed: A. immediately after a meal B. right before a meal C. 1-2 hours after a meal D. only at bedtime

C. 1-2 hours after a meal Rationale: It is best to perform CPT 1-2 hours after a meal (in between meals). You wouldn't want to do it immediately after a meal due to aspiration or vomiting risk OR right before because this can alter a patient's appetite due to the mucous that will be expelled (the mucous can have a foul taste or odor to it), and option D is wrong because CPT is done up to 2-4 times a day NOT only at bedtime.

The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client's condition should the nurse report to the primary healthcare provider within 24 hours after observation? A.Client A - burning, itching discharge from eyes B.Client B - blood in urine C.Client C - yellow discoloration of the skin D.Client D - nausea, vomiting and abdominal pain

C. Client C - yellow discoloration of the skin Rationale: A client with an HIV infection is at risk of multiple diseases. Burning, itching, and discharge from the eyes are not life-threatening and can be reported within 24 hours. All the other clients' conditions should be reported immediately

The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.6 mg/dL B. Serum potassium of 3.8 mEq/L C. Serum hemoglobin of 14.7 g/dL D. Blood glucose level of 98 mg/dL

A. Serum creatinine of 2.6 mg/dL Rationale: The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? A. 108/64 mm Hg B. 120/76 mm Hg C. 140/90 mm Hg D. 136/ 82 mm Hg

B. 120/76 mm Hg Rationale: The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

A patient with ESRD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood? A. Calcium B. Urea C. Phosphate D. Erythropoietin

B. Urea Rationale: This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this.

A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. What disorder is this patient most likely experiencing? A. Addisonian Crisis B. Cushing Syndrome C. Thyroid crisis D. Hashimoto thyroiditis

A. Addisonian Crisis Rationale: Note the patient is experiencing the signs and symptoms of Addisonian Crisis. The red flag in this scenario are the patient's symptoms, recent hospitalization diagnosis, and that she is not taking any medications. Remember that patients who have Addision's disease are at risk for Addisonian Crisis, especially if they are not taking their prescribed hormone therapy replacement.

Select ALL of the following that are complications associated with Crohn's Disease: A. Cobble-stone appearance of GI lining B. Lead-pipe sign C. Toxic megacolon D. Fistula E. Abscess F. Anal Fissure

A. Cobble-stone appearance of GI lining D. Fistula E. Abscess F. Anal Fissure Rationale: The answers are A, D, E, and F. These are all complications found with Crohn's Disease. Lead-pipe sign and toxic megacolon are complications associated with ulcerative colitis.

A female client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? A.Depression B.Neuropathy C.Hypoglycemia Hyperthyroidism

A. Depression Rationale: Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? A. Elevated creatinine level B. Decreased hemoglobin level C. Decreased red blood cell count D. Increased number of white blood cells in the urine

A. Elevated creatinine level Rationale: The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

A patient with hypothyroidism is having pain 6 on 1-10 scale in the right hip due to recent hip surgery. Which of the following medications are NOT appropriate for this patient? Select all that apply: A. Fentanyl B. Tylenol C. Morphine D. Dilaudid

A. Fentanyl C. Morphine D. Dilaudid Rationale: Patients who have hypothyroidism are very sensitive to narcotics and should take NON-NARCOTICS for pain relief. Fentanyl, Morphine, and Dilaudid are all narcotics, whereas, Tylenol is not.

For the first 72 hours after a thyroidectomy surgery, nurse Jaime would assess the female client for Chvostak's sign and Trousseau's sign because they indicate which of the following? A. Hypocalcemia B. Hypercalcemia C. Hypokalemia D. Hyperkalemia

A. Hypocalcemia Rationale: The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs are not present with the other listed options.

A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious, she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. In the scenario above, what medication do you expect the patient to be started on? A. IV Solu-Cortef B. PO Prednisone C. PO Declomycin D. IV Insulin

A. IV Solu-Cortef Rationale: The patient needs cortisol immediately because they are experiencing Addisonian Crisis. IV Solu-Cortef is the best option because it is intravenous and a glucocorticoid. The patient is unconscious and can not take oral medications, therefore Prednisone is not the best option and all the other options are incorrect.

In Cushing's Disease and syndrome, there are: A.Increased cortisol production B.Low potassium and glucose levels C.Increased production of aldosterone and cortisol Decreased production of cortisol and aldosterone

A. Increased cortisol production Rationale: Option A is correct because an increased level of cortisol production is what causes Cushing's.

Major signs and symptoms of Cushing's include which of the following? Select all that apply. A.Moon face B.Excess adipose tissue in legs C.Buffalo hump D.Striae Decreased susceptibility to infection

A. Moon face C.Buffalo hump D.Striae Rationale: Signs/ symptoms of Cushing's can present as weight gain/ fatty tissue deposits in face otherwise known as "moon face," between shoulders known as "buffalo hump," and reddish- blue stretch marks otherwise known as "striae."

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? A.. My pain goes away when I have a bowel movement B. I have bright red blood in my stool all the time. C. I have episodes of diarrhea and constipation. D. My abdomen is hard and rigid, and I have a fever.

A. My pain goes away when I have a bowel movement Rationale: The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.

The nurse is volunteering at a community center to teach women about breast cancer. What should the nurse include when discussing risk factors? (SATA) A. Nulliparity B. Age 30 or over C. Early menarche D. Late menopause E. Personal history of colon cancer

A. Nulliparity C. Early menarche D. Late menopause E. Personal history of colon cancer Rationale: Women are at an increased risk for development of breast cancer if they are over the age of 50; have a family history of breast cancer; have a personal history of breast, colon, endometrial, or ovarian cancer; have a long menstrual history as seen with early menarche or late menopause; and have had a first full-term pregnancy after the age of 30 or are nulliparous.

Select the systems below that are affected by cystic fibrosis: A. Reproductive B. Lymphatic C. Respiratory D. Gastrointestinal E. Neuro F. Integumentary

A. Reproductive C. Respiratory D. Gastrointestinal F. Integumentary Rationale: Cystic fibrosis affects the respiratory system (this causes thick mucus to build up in the lungs and it can affect both the upper and lower respiratory system like the sinuses), gastrointestinal (pancreas, intestines, and liver are all affected due to thick mucus), and integumentary (skin's sweat glands will make extremely salty sweat).

A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance? A. respiratory acidosis B. respiratory Alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Rationale: Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships.

You are administering erythropoietin to the patient with ESRD. Which of the following would be a sign of adverse reaction? Select all that apply A. Seizure B. Hypertension C. Decreased u/o D. Improved exercise tolerance E. Headache

A. Seizure B. Hypertension E. Headache Rationale: Seizures, Hypertension, HA, arthralgia, nausea, increased clotting of vascular access sites, seizures, and depletion of body iron stores are adverse effects of administering erythropoietin. Decreased u/o is a symptom of the disease process. Improved exercise tolerance would be a benefit of this medication.

In the administration of hydrocortisone (Aeroseb-HC, Alphadern, Cetacort), it is vital that the nurse recognize that this drug might mask which symptoms? A. Signs and symptoms of infection B. Signs and symptoms of heart failure C. Hearing loss D. Skin infections

A. Signs and symptoms of infection Rationale: These drugs cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections.

A nurse is teaching a health class about human immunodeficiency virus (HIV). Which basic methods are used to reduce the incidence of HIV transmission? Select all that apply. A.Using condoms B.Using separate toilets C.Practicing sexual abstinence D.Preventing direct casual contacts E.Sterilizing the household utensils

A. Using condoms C. Practicing sexual abstinence Rationale: HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.

The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Select all that apply. A. instill isotonic eye drops as necessary B. provide several, small, well-balanced meals C. provide rest periods D. keep the environment warm E. encourage frequent visitors and conversation F. weigh the client daily

A. instill isotonic eye drops as necessary B. provide several, small, well-balanced meals F. weigh the client daily Rationale: The client with hyperthyroidism may experience exophthalmos. This requires instillation of eye drops to prevent dryness and ulceration of the cornea. The client experiences weight loss because of the increased metabolic rate. Several, small, and well-balanced meals are given to improve nutritional status of the client. Daily weights should be monitored as weight is the most objective indicator of nutritional status. The client is usually exhausted due to restlessness and agitation. E is not appropriate for this reason, D is not appropriate as the patient experiences heat intolerance.

The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when A. the patient appears alert and oriented B. the patient's urinary output has increased C. pulmonary edema is reduced as evidenced by clear lung sounds D. laboratory tests reveal serum elevations of K and glucose and a decrease in sodium

A. the patient appears alert and oriented Rationale: confusion, irritability, disorientation, or depressioni s often present in the patient with Addison's dz, and a positive response to therapy would be indicated by a return to alertness and orientation. Other indication of response to therapy would be a decreased urinary output, decreased serum potassium, and increased serum sodium and glucose. The patient with Addison's would be very dehydrated and volume-depleted and would not have pulmonary edema

Which topic is most important for the nurse to teach in a community health promotion class of middle-aged adults? A.Cessation of Smoking B.Prevention of infection C.Abstinence from alcohol D.Decreasing high density lipoproteins levels

A.Cessation of Smoking Rationale: Smoking is a major risk factor for cardiovascular disease and hypertension which are major health problems of middle-aged adults. Middle-aged adults are not at greater risk for infection. Alcohol intake should be limited, but abstinence is not required for prevention of health problems. High density lipoprotein (HDL) levels should be increased to help prevent cardiovascular disease.

You're providing diet teaching to a patient with ulcerative colitis about what types of foods to avoid during a "flare-up". Which foods below should the patient avoid? Select all that apply. A.Ice cream B.White Rice C.Fresh apples and pears D.Popcorn E.Cooked carrots

A.Ice cream C.Fresh apples and pears D.Popcorn Rationale: Patients experiencing a flare-up with ulcerative colitis should avoid dairy products (ice cream), food that are high in fiber (fresh apples or pears) (cooked fruits without the skin would be okay), and foods that are hard to digest (popcorn). Instead, patients should consume foods low in fiber (low residue) like cooked vegetables (carrots), bland foods (white rice) etc.

An obese patient is diagnosed with obstructive sleep apnea. Which conservative approaches are included in the patient's treatment plan? Select all that apply. A.Limit alcohol consumption. B.Motivate the patient to lose weight. C.Recommend that the patient take sedatives. D.Recommend that the patient take herbal medicines. E.Avoid the consumption of stimulants before going to bed.

A.Limit alcohol consumption. B.Motivate the patient to lose weight. E.Avoid the consumption of stimulants before going to bed. Rationale: In obstructive sleep apnea, the upper airways become partially or completely blocked, diminishing nasal airflow or stopping it for as long as 30 seconds. Consumption of alcohol interferes with the quality of sleep. Weight reduction is helpful in decreasing sleep apnea, because it helps to reduce airway obstruction and promotes lung expansion. Consumption of stimulants causes sleeplessness, so they should be avoided. Sedatives should only be prescribed by the health care provider. Herbal medicines may produce side effects or interact with other medications the patient is already taking.

A patient has a history of obstructive sleep apnea. Which postoperative care reduces the risk of any complications in the patient? Select all that apply. A.Using an oral appliance B.Monitoring the patient's airway C.Avoiding the elevation of the head of the bed D.Sleeping in the supine position E.Using a nasal continuous positive airway pressure (CPAP) device

A.Using an oral appliance B.Monitoring the patient's airway E.Using a nasal continuous positive airway pressure (CPAP) device Rationale: Patients with obstructive sleep apnea have a risk of developing postoperative complications. Following surgery, the patient may reach deep levels of rapid eye movement sleep that cause muscle relaxation. This muscle relaxation can worsen obstructive sleep apnea and obstruct the airway. An oral appliance can be used to keep the airway patent by advancing the mandible or tongue to relieve pharyngeal obstruction. The nurse should monitor the patient for an increased risk of respiratory complications. Using a nasal continuous positive airway pressure device helps to prevent airway collapse. The patient would be more comfortable if the head of the bed were elevated. The patient should not sleep in the supine position, because it may obstruct the airway.

A nurse is planning a teaching program for a patient with a diagnosis of obstructive sleep apnea. Which should the nurse plan to discuss with this patient? A.Using the ordered device that supports airway patency B.Placing two pillows under the head when sleeping C.Requesting a sedative to promote sleep D.Sleeping in the supine position

A.Using the ordered device that supports airway patency Rationale: A continuous positive airway pressure (CPAP) device worn when sleeping keeps the upper airway patent by maintaining an open pathway that facilitates gas exchange.

The nurse has been asked to participate in a healthy living workshop. While teaching about women's health, which guidelines should the nurse provide to the audience? A. "Mammograms are necessary if you have a family history of breast cancer." B. "It's recommended that you get a mammogram each year after you turn 40." C. "If you are not able to perform breast self-examination (BSE), you should go for regular mammograms." D. "You should ensure that your primary care provider performs a breast exam each time you visit."

B. "It's recommended that you get a mammogram each year after you turn 40." Rationale: Annual mammograms are recommended after age 40. They are recommended for all women, not solely those with a family history of breast cancer. BSE is not a replacement for mammography, and clinical breast examinations are not necessary at each office visit but recommended at least every 3 years for women in their 20s and 30s, and then every year beginning at age 40.

Which of the following patients are at risk for developing Cushing's Syndrome? A. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. B. A patient taking glucocorticoids for several weeks. C. A patient with a tuberculosis infection. D. A patient who is post-opt from an adrenalectomy

B. A patient taking glucocorticoids for several weeks. Rationale: A patient taking glucocorticoids for several weeks. Remember that CUSHING'S DISEASE is caused by the pituitary gland producing too much ACTH which in turn increases cortisol. Cushing's SYNDROME can be caused by medication therapy of glucocorticoids. An adrenalectomy is a treatment for Cushing's Disease (so this is not the answer in this case) and TB is a risk factor for developing ADDISON'S Disease.

A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia

B. Anemia Rationale: EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.

With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. A.Applying lotion during a back rub B.Brushing the client's teeth C.Emptying a Foley catheter reservoir D.Feeding the client E.Filing the client's fingernails F.Providing perineal care

B. Brushing the client's teeth C. Emptying a Foley catheter reservoir F. Providing perineal care Rationale: Standard Precautions for preventing the spread of any type of infection including HIV requires wearing gloves when coming into contact with moist mucous membranes, including oral and perineal membranes. Although saliva has a low concentration of HIV unless blood is present, oral mucous membranes harbor many types of infectious organisms.Standard precautions also require that gloves be worn when contact with urine is possible, including during such tasks as emptying a Foley catheter reservoir.Perspiration is not considered a body fluid with risk for transmission and neither is in contact with the client's intact skin.Feeding the client should not result in direct contact with transmissible fluids and neither should clipping finger nails.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. A. Olive oil B. Chicken Broth C. Enriched Whole milk D. Red meats, such as beef E. Vegetables and whole grains F. Liver and other glandular organ meats

B. Chicken Broth C. Enriched Whole milk D. Red meats, such as beef F. Liver and other glandular organ meats Rationale: Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease

A patient is newly diagnosed with COPD due to chronic bronchitis. You're providing education to the patient about this disease process. Which statement by the patient indicates they understood your teaching about this condition? A. "If I stop smoking it will cure my condition. B. Complications from this condition can lead to pulmonary hypertension and right-sided heart failure. C. I'm at risk for low levels of red blood cells due to hypoxia and may require blood transfusions during acute illnesses. D. My respiratory system is stimulated to breathe due to high carbon dioxide levels rather than low oxygen levels.

B. Complications form this condition can lead to pulmonary hypertension and right-sided heart failure. Rationale: option A is wrong because smoking cessation will NOT cure the condition, but it may slow down the progress of it. Option C is wrong because the patient may develop HIGH LEVELS of red blood cells due to the body trying to compensate for hypoxia. Option D is wrong because patients with COPD are stimulated to breathe due to LOW OXYGEN LEVELS rather than high carbon dioxide levels.

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? A. Decreased Breath Sounds B. Elevated Serum Troponin C. Decreased Creatinine Kinase (CK-MB) D. Elevated brain natriuretic peptide (BNP) level

B. Elevated Serum Troponin Rationale: Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? A. Contact the provider and recommend a psychiatric consult for the client. B. Encourage the client to verbalize feelings about the diagnosis. C. Provide education about new treatment options with successful outcomes. D. Ask family and friends to visit the client and provide emotional support.

B. Encourage the client to verbalize feelings about the diagnosis. Rationale: The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support.

Which of the following assessment findings characterize thyroid storm? A. Increased body temperature, decreased pulse, and increased blood pressure B. Increased body temperature, increased pulse, and increased blood pressure C. Increased body temperature, decreased pulse, and decreased blood pressure D. Increased body temperature, increased pulse, and decreased blood pressure

B. Increased body temperature, increased pulse, increased blood pressure Rationale: Thyroid storm is characterized by sympathetic nervous system activation. Thyroid hormones potentiate the effects of catecholamine's (epinepherine/norepinepherine). Therefore, all listed vital signs will be increased.

Nurses should expect a client with hypothyroidism to report which health concerns? A. Increased appetite and weight loss B. Puffiness of the face and hands C. Nervousness and tremors D. Thyroid gland swelling

B. Puffiness of the face and hands Rationale: Hypothyroidism causes facial puffiness, extremity edema, and weight gain.

You're educating the parents of an 8-month-old, who was recently diagnosed with cystic fibrosis, about the disease. You explain to the parents that the child has a gene mutation on the ____________. The gene that is specifically mutated is called? A. endocrine glands; Hbg S gene B. exocrine glands; CFTR gene C. endocrine glands; Chromosome 21 D. exocrine glands; HTT gene

B. exocrine glands; CFTR gene Rationale: Cystic fibrosis affects the EXOCRINE glands, specifically the Cystic Fibrosis Transmembrane Regulator gene (CFTR). This is a protein that controls the channels of sodium and chloride...hence the sodium and water transport in and out of the cell. These channels are within the membrane of these cells that makes our sweat, mucous, tears, digestive enzymes. Since it is mutated the fluids that are normally thin now become very thick and sticky, which causes many problems in the organs like the lungs, pancreas, intestine etc.

Which patient is at highest risk for obstructive sleep apnea? A.82-year-old male with Parkinson's disease who has dysphagia B.68-year-old obese male who smokes one pack of cigarettes per day C.18-year-old female with cystic fibrosis who has recurrent pneumonia D.35-year-old female with a BMI of 22 kg/m2 who has seasonal allergies to pollen

B.68-year-old obese male who smokes one pack of cigarettes per day Rationale: Risk of obstructive sleep apnea increases with obesity (BMI > 28 kg/m2), age more than 65 years, neck circumference > 17 inches, craniofacial abnormalities, and acromegaly. Smokers are more at risk for OSA, and OSA is more common in men than women.

You're educating a group of outpatients about signs and symptoms of ulcerative colitis. Which of the following are NOT typical signs and symptoms of ulcerative colitis? Select all that apply. A.Rectal Bleeding B.Abdominal mass C.Bloody diarrhea D.Fistulae E.Extreme Hunger Anemia

B.Abdominal mass D.Fistulae E.Extreme Hunger Rationale: Rectal bleeding, bloody diarrhea, and anemia are present in ulcerative colitis. However, an abdominal mass or fistulae tends to be present with Crohn's Disease. Loss of appetite rather than extreme hunger presents in ulcerative colitis.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. A.Assessing the client's bowel sounds. B.Providing skin care following bowel movements. C.Evaluating the client's response to antidiarrheal medications. D.Maintaining intake and output records. E.Obtaining the client's weight.

B.Providing skin care following bowel movements. D.Maintaining intake and output records. E.Obtaining the client's weight. Rationale: The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply. A.Dyspnea on exertion B.Unexplained profuse diaphoresis C.Indigestion not relived by antacids D.Fatigue the day after a rigorous walk E.Acute chest pain after rigorous exercise F.Nonremitting chest pain after three sublingual nitroglycerine tablets

B.Unexplained profuse diaphoresis C.Indigestion not relived by antacids E.Acute chest pain after rigorous exercise F. Nonremitting chest pain after three sublingual nitroglycerine tablets Rationale; Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest pain after rigorous exercise, and nonremitting chest pain after three sublingual nitroglycerine tablets are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical intervention. Dyspnea on exertion and fatigue the day after a rigorous walk are expected.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? A. Obtain a BP reading in each arm and average the results. B. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. C. Have the patient sit in a chair with the feet flat on the floor. D. Assist the patient to the supine position for BP measurements.

C Have the patient sit in a chair with the feet flat on the floor Rationale: The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. A. "If I limit my fluid intake I will not have to empty my ostomy pouch as often." B. "I can place an aspirin tablet in my pouch to decrease odor." C. "I can usually keep my ostomy pouch on for 3 to 7 days before changing it." D. "I must use a skin barrier to protect my skin from urine." E. "I should empty my ostomy pouch of urine when it is full."

C. "I can usually keep my ostomy pouch on for 3 to 7 days before changing it." D. "I must use a skin barrier to protect my skin from urine." Rationale: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

You are teaching the patient starting hemodialysis. Which statement, if made by the patient, indicates the need for further teaching? A."To protect my fistula I shouldn't wear tight fitting clothing on that side" B. "If I see any redness or swelling on the site, I should call my doctor" C. "I shouldn't sleep on my side with the graft but it's ok to take a blood pressure on that arm" D. "I need to wait to take my medications until after my dialysis treatment"

C. "I shouldn't sleep on my side with the graft but it's ok to take a blood pressure on that arm" Rationale: It is not ok to take a blood pressure on the side with the dialysis site. The patient should also be taught to avoid tight fitting clothes, blood draws, iv insertions, carrying bags/pocketbooks, or sleeping on the affected side. Redness and swelling are signs of infection that should be reported to the doctor. Because hemodialysis can cause medication accumulation and toxicity patients are advised to take daily medications after dialysis treatment.

A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up? A."I will ask the client to avoid exposure to new infectious agents." B."I will ask the client about intake of vitamins and micronutrients." C."I will ask the client to avoid involvement in community activities." D."I will ask the client if he or she is up to date with recommended vaccines."

C. "I will ask the client to avoid involvement in community activities." Rationale: HIV-infected clients may feel isolated and lonely; therefore they should be involved in support groups and community activities. The nurse should follow up to correct this misconception. All the other statements are correct. The HIV infection decreases the client's immunity making the client prone to infection. Therefore HIV-infected clients should avoid exposure to new infectious agents. They should consume nutritional support to maintain lean body mass and ensure appropriate levels of vitamins and micronutrients. They need to be updated with recommended vaccines to prevent vaccine-preventable diseases.

Which patient below is NOT at risk for developing chronic kidney disease? A. A 58-year-old female with uncontrolled hypertension B. A 69-year-old male with diabetes mellitus C. A 45-year-old female with polycystic ovarian disease D. A 78-year-old female with an intrarenal injury

C. A 45-year-old female with polycystic ovarian disease Rationale: Options A, B, and D are all at risk for developing CKD. However, option C is not at risk for CKD.

A nurse is caring for a client hospitalized with acute exacerbation of COPD. Which of the following would the nurse expect to note on assessment of this client? A. Increased oxygen saturation with exercise B. Hypocapnia C. A hyperinflated chest on x-ray film D. A widened diaphragm noted on chest x-ray film

C. A hyperinflated chest on x-ray film Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray films reveal a hyperinflated chest and a flattened diaphragm is the disease is advanced.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? A. Your doctor should not have given you that information prior to the colonoscopy. B. The colonoscopy is required due to the high percentage of false negatives with the blood test. C. A negative fecal occult blood test does not rule out the possibility of colon cancer. D. I will contact your doctor so that you can discuss your concerns about the procedure.

C. A negative fecal occult blood test does not rule out the possibility of colon cancer. Rationale: A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized, and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit: A. Is a temporary procedure that can be reversed later. B. Diverts urine into the sigmoid colon, where it is expelled through the rectum C. Conveys urine from the ureters to a stoma opening in the abdomen D. Creates an opening in the bladder that allows urine to drain into an external pouch.

C. Conveys urine from the ureters to a stoma opening in the abdomen Rationale: An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected and one end of the segment is closed. The ureters are surgically attached to this segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form the stoma. The client must wear a pouch to collect the urine that continually flows through the conduit. The bladder is removed during the surgical procedure and the ileal conduit is not reversible. Diversion of the urine to the sigmoid colon is called a ureter ileosigmoidostomy. An opening in the bladder that allows urine to drain externally is called a cystostomy.

Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: A.Hypotension. B.Thick, coarse skin. C.Deposits of adipose tissue in the midsection and upper back. D.Weight gain in arms and legs.

C. Deposits of adipose tissue in the midsection and upper back. Rationale: Option C is correct because of changes in fat distribution, adipose tissue accumulates in the upper back or trunk, face, and midsection. Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities

A patient with emphysema may present with all of the following symptoms EXCEPT? A. Barrel chest B. Hyperinflation of the lungs C. hypoventilation D. Hypercapnia

C. Hypoventilation Rationale: Patients with emphysema present with Hyperventilation. The body will try to compensate for the low oxygen blood levels and will cause the patient to hyperventilate. Remember emphysema patients are sometimes called "pink puffers". They will have a barrel chest due to the use of accessory muscles for breathing), hyperinflation of the lungs (due to damage of the alveoli sacs and creation of air sacs), and hypercapnia (high carbon dioxide levels)

The client diagnosed with Crohn's disease is crying and tells the nurse, I can't take it anymore. I never know when I will get sick and end up here in the hospital. Which statement is the nurse's best response? A. I understand how frustrating this must be for you. B. You must keep thinking about the good things in your life. C. I can see you are very upset. I'll sit down and we can talk D. Are you thinking about committing suicide?

C. I can see you are very upset. I'll sit down and we can talk Rationale: The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk.

A patient with Addison's disease comes to the emergency department with complaints of N/V/D, and fever. The nurse would expect collaborative care to include A. parenteral injections of ACTH B. IV administration of vasopressors C. IV administration of hydrocortisone D. IV administration of D5W with 20mEq of KCl

C. IV administration of hydrocortisone Rationale: vomiting and diarrhea are early indicators of addisonian crisis and fever indicates an infection, which s causing additional stress for the patient. treatment of a crisis requires immediate glucocorticoid replacement, and IV hydrocortisone, fluids, sodium and glucose are necessary for 24hours. Addison's disease is a primary insufficiency of the adrenal gland, and ACTH is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's. Potassium levels are increased in Addison's dz, and KCl would be contraindicated

When doing breast self-examination, the female patient should report which findings to her physician? A. Palpable rib margins B. Denser breast tissue C. Left nipple deviation D. Different sized breasts

C. Left nipple deviation Rationale: Unilateral deviation of a nipple may be a clinical indicator of breast cancer or other problem and should be reported to the health care provider. Dense breast tissue, palpable rib margins, and different sized breasts are all normal findings.

The most important long-term goal for a client with hypertension would be to: A. Learn how to avoid stress B. Explore a job change or retire C. Make a commitment to long-term therapy D. Control Blood pressure

C. Make a commitment to long term therapy Rationale: Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance.

The nurse is caring for a 52-year-old woman with breast cancer who is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make? A. Observe for alopecia. B. Determine visual acuity. C. Monitor cardiac rhythm. E. Assess mouth and throat.

C. Monitor cardiac rhythm. Rationale: Doxorubicin (especially at high doses) may cause cardiotoxicity and heart failure. The nurse should monitor for cardiac dysrhythmias, electrocardiogram changes, and clinical manifestations of heart failure. Other adverse effects of doxorubicin include stomatitis and alopecia, but these effects are not as serious as cardiac problems. Tamoxifen may cause visual changes.

Which of the following symptoms is the most common clinical finding associated with bladder cancer? A. Suprapubic pain B. Dysuria C. Painless hematuria D. Urinary retention

C. Painless hematuria Rationale: Painless hematuria is the most common clinical finding in bladder cancer. Other symptoms include frequency, dysuria, and urgency, but these are not as common as the hematuria. Suprapubic pain and urinary retention do not occur in bladder cancer.

A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition? A. Tapazole B. PTU (Propylthiouracil) C. Synthroid D. Inderal

C. Synthroid Rationale: Synthroid is a synthetic hormone preparation used in hormone replacement therapy for those with hypothyroidism

A female client with hypothyroidism (myxedema) is receiving levothyroxine (synthroid), 25 mcg P.P. daily. Which finding should the nurse recognize as an adverse drug effect? A.Dysuria B.Leg cramps C.Tachycardia D.Blurred vision

C. Tachycardia Rationale: Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to stimulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine

A patient with Crohn's Disease is most likely to have the disease is what part of the GI tract? A. Rectum B. Duodenum of the small intestine C. Terminal Ileum D. Descending colon

C. Terminal Ileum Rationale: Crohn's disease is MOST likely to affect the terminal ileum. However, it may affect any area of the GI tract.

A patient completed a sweat test yesterday. The results are back and are 45 mmol/L. As the nurse you know this means: A. The patient tested positive for cystic fibrosis. B. The patient tested negative for cystic fibrosis. C. The patient needs further testing because results are not conclusive.

C. The patient needs further testing because results are not conclusive. Rationale: A sweat test is gold standard in testing for cystic fibrosis.

You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. What would you include to best promote learning and adherence of the participants (SATA)? A. Short audiotape on the BSE procedure B. Packet of articles from the medical literature C. Written guidelines for mammography and CBE D. Discussion of the value of early breast cancer detection E. Need to get mammogram starting at age 35

C. Written guidelines for mammography and CBE D. Discussion of the value of early breast cancer detection Rationale: When teaching women about breast cancer screening guidelines, include information about potential benefits, limitations, and harm (chance of a false-positive result). Allow time for questions about the procedure and a return demonstration. At every periodic health examination, ask the woman who is performing BSE to demonstrate her technique. Demonstration of BSE and provision of written guidelines are appropriate teaching methods.

You're assisting a patient with performing chest physiotherapy. It is very important you have the patient ___________ during the therapy sessions. A. bear down B. use the incentive spirometer C. huff cough D. use a peak flow meter

C. huff cough Rationale: This is a special type of coughing that will help the patient cough up the mucous during the CPT. It is very important the patient performs this during their CPT sessions.

You suspect kidney transplant rejection when the patient shows which symptoms? A.Pain in the incision, general malaise, and hypotension B.Pain in the incision, general malaise, and depression C.Fever, weight gain, and diminished urine output D.Diminished urine output and hypotension

C.Fever, weight gain, and diminished urine output Rationale: Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the graft site, peripheral edema, and diminished urine output.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs? A.Initiate continuous enteral feedings B.Encourage a high protein, high-calorie diet C.Implement total parenteral nutrition D.Provide six small meals a day

C.Implement total parenteral nutrition Rationale: Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: A.Thyroid storm B.Cretinism C.Myxedema coma D.Hashimoto's thyroiditis

C.Myxedema coma Rationale: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

You're providing teaching to a patient who has been newly diagnosed with Crohn's Disease. Which statement by the patient's spouse requires re-education? A. "Crohn's Disease can be scattered throughout the GI tract in patches with some areas appearing healthy while others are diseased." B. "There is no cure for Crohn's Disease." C. "Strictures are a common complication with Crohn's Disease." D. "Crohn's Disease can cause the haustra of the large intestine to lose its form."

D. "Crohn's Disease can cause the haustra of the large intestine to lose its form." Rationale: All the statements are true except option D. ULCERATIVE COLITIS can cause the haustra of the large intestine to lose its form. This is not common with Crohn's Disease.

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action? A. Provide the client with information about the usefulness of herbal therapies B. Inform the client about taking supplemental vitamins rather than herbs C. Teach the client about herbal supplements D. Ask the client with herbs have been taken

D. Ask the client with herbs have been taken Rationale: The nurse must find out which herbs the client has been taking because some herbs can cause hemorrhage, and the healthcare provider may need to postpone the surgery until the client has been free of herbal supplements for a period of time. Although the client may be interested in the usefulness of the herbal therapies being taken, this is not the appropriate time for this teaching. Teaching or talking about the differences in supplemental vitamins and herbs is not the priority in this situation. Although some herbs are dangerous, others have proved beneficial, but this teaching is not the priority action.

If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis? A.Abdominal computed tomography (CT) scan B.Abdominal x-ray C.Barium swallow D. Colonoscopy with biopsy

D. Colonoscopy with biopsy Rationale: A colonoscopy with biopsy can be performed to determine the state of the colon's mucosal layers, presence of ulcerations, and level of cytologic development. An abdominal x-ray or CT scan wouldn't provide the cytologic information necessary to diagnose which disease it is. A barium swallow doesn't involve the intestine.

A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? A.Adhere to standard precautions at all times B.Avoid handling equipment used in direct client care C.Disinfect all equipment used for non-invasive procedures D.Discuss procedures that can be performed with a review panel

D. Discuss procedures that can be performed with a review panel Rationale: Workers who are infected with HIV should seek advice from an expert review panel before performing exposure-prone procedures to determine under what circumstances they may continue to practice these procedures. All healthcare workers should adhere to standard precautions at all times and not just those who are HIV positive. Workers with exudative lesions or weeping dermatitis should not perform direct client care or handle client care equipment and devices used in invasive procedures. Workers must follow guidelines for disinfection and sterilization of reusable equipment utilized in invasive procedures.

A female client with a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." The most appropriate nursing diagnosis for this patient is: A. Anxiety related to the presence of urinary diversion. B. Deficient Knowledge about how to care for the urinary diversion C. Low Self-Esteem related to feelings of worthlessness D. Disturbed Body Image related to creation of a urinary diversion

D. Disturbed Body Image related to creation of a urinary diversion Rationale: It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggest that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner. Although the client may be anxious about this situation and self-esteem may be diminished, the underlying problem is disturbance in body image. There are no data to support a diagnosis of Deficient Knowledge.

A patient with hyperthyroidism is taking propylthiouracil (PTU). The nurse will monitor the patient for: A. gingival hyperplasia and lycopenemia B. Dyspnea and a dry cough C. Blurred vision and nystagmus D. Fever and sore throat

D. Fever and sore throat Rationale: Fever and sore throat are signs of a serious adverse reaction in PTU and should be reported immediately. An adverse affect of PTU is agranulocytosis which makes the patient taking PTU more susceptible for infection

Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics? A. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart B. How to increase his oxygen therapy C. How to treat respiratory infections without going to the physician D. How to recognize the signs of an impending respiratory infection

D. How to recognize the signs of an impending respiratory infection Rationale: Respiratory infection in clients with a respiratory disorder can be fatal. It's important that the client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate for the wife to listen to his lung sounds; besides, you can't purchase stethoscopes from Wal-Mart. If the client has signs and symptoms of an infection, he should contact his physician at once.

Which nursing diagnosis takes highest priority for a female client with hyperthyroidism? A. Risk for imbalanced nutrition: more than body requirements related to thyroid hormone excess B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing C. Body image disturbance related to weight gain and edema D. Imbalanced nutrition: less than body requirements related to thyroid hormone excess

D. Imbalanced nutrition: less than body requirements related to thyroid hormone excess Rationale: In a client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making this nursing diagnosis the most important.B/C may be more appropriate for hypothyroidism, which slows metabolic rate.A is unlikely to occur

The nurse is taking care of the patient with chronic kidney disease. Which of the following meal trays would be the best for this patient? A. Whole grain roll with baked chicken and pea soup and milk B. Sandwich with smoked salmon lunchmeat, green beans, and banana pudding C. Baked ham, mashed potatoes, tomato soup and peanut butter cookies D. Low-sodium chicken noodle soup, apple slices, white-wheat roll, and rice

D. Low-sodium chicken noodle soup, apple slices, white-wheat roll, and rice Rationale: This tray contains a small amount of protein and an adequate amount of carbohydrates that are low in sodium and potassium. Although a whole-grain roll would be appropriate with baked chicken. Pea soup and the milk would be high in potassium and protein. Smoked meats are often high in sodium. Tomato soup and peanut butter would add extra potassium and protein to this patient's diet

The kidneys are responsible for performing all the following functions EXCEPT? A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production

D. Maintaining cortisol production Rationale: The adrenal glands are responsible for maintain cortisol production not the kidneys

The kidneys are responsible for performing all the following functions EXCEPT? A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production

D. Maintaining cortisol production Rationale: The adrenal glands are responsible for maintaining cortisol production not the kidneys.

A client is receiving a radiation implant for the treatment of bladder cancer. Which of the following interventions is appropriate? A. Flush all urine down the toilet B. Restrict the client's fluid intake C. Place the client in a semi-private room D. Monitor the client for signs and symptoms of cystitis

D. Monitor the client for signs and symptoms of cystitis Rationale: Cystitis is the most common adverse reaction of clients undergoing radiation therapy; symptoms include dysuria, frequency, urgency, and nocturia. Clients with radiation implants require a private room. Urine of clients with radiation implants for bladder cancer should be sent to the radioisotopes lab for monitoring. It is recommended that fluid intake be increased.

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? A. Seating the client with arm bared, supported, and at heart level. B. Measuring the blood pressure after the client has been seated quietly for 5 minutes. C. Using a cuff with a rubber bladder that encircles at least 80% of the limb. D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. Rationale: BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy.

When assessing a client for obstructive sleep apnea (OSA), the nurse understands the most common symptom is: A.Headache B.Early awakening C.Impaired reasoning D.Excessive daytime sleepiness

D.Excessive daytime sleepiness Rationale: Excessive daytime sleepiness is the most common complaint of people with OSA. Persons with severe OSA may report taking daytime naps and experiencing a disruption in their daily activities because of sleepiness.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? A. Eat low-fiber and low-residual foods. B. White rice and bread are easier to digest. C. Add vegetables such as broccoli and cauliflower to your new diet. D. Foods high in animal fat help to protect the intestinal mucosa.

b. Add vegetables such as broccoli and cauliflower to your new diet. Rationale: The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? A. I have a good friend with a colostomy who would be willing to talk with you. B. The enterostomal therapist will be able to answer all of your questions. C. I will make a referral to the United Ostomy Associations of America. D. You'll find that most people with colostomies don't want to talk about them.

c. I will make a referral to the United Ostomy Associations of America. Rationale: Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care? A. You may experience nausea and vomiting for the first few weeks. B. Carbonated beverages can help decrease acid reflux from anastomosis sites. C. Take a stool softener to promote softer stools for ease of defecation. D. You may return to your normal workout schedule, including weight lifting.

c. Take a stool softener to promote softer stools for ease of defecation. Rationale: Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.