T3
A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?
Caregiver cleans the client's anal area without wearing gloves
A nurse plans to have an education session with a client with cardiomyopathy and the client's spouse about ways to increase activity tolerance. What instructions would the nurse provide?
Alternate active periods with rest periods.
The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?
Report the incident to the supervisor.
The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?
"Be sure to apply a moisturizer to feet daily."
The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?
"How do you prepare your food?"
A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response?
"Hypertension greatly increases your risk of stroke and heart disease."
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
"I have difficulty breathing when walking 30 feet."
A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease?
"I skip lunch when I don't feel hungry."
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
"I was chewing ice chips all day long."
The nurse is instructing a client about taking corticosteroid therapy for adrenal insufficiency. What statement made by the client indicates a need for further instruction?
"I will take the corticosteroid medication until my adrenal glands begin to work."
The client asks the nurse if dipstick of urine can be used for monitoring glucose levels. Which is the best response by the nurse?
"The most accurate way to monitor glucose levels is by blood testing."
A recently widowed diabetic comments that her blood sugar levels are running higher than usual. Which is the best response from the nurse?
"This must be a stressful time for you."
A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse?
"Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."
A client is receiving immunotherapy as part of the treatment plan for an allergic disorder. After administering the therapy, the client states, "I guess I can go home now." Which response by the nurse would be most appropriate?
"You need to stay about another half-hour so we can make sure you don't have a reaction."
A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?
6.5%
A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon, the girl develops erythema and itching around her mouth. This is likely due to which of the following?
A latex allergy
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly?
A pituitary tumor
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Administer an over-the-counter decongestant.
The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic?
Airborne pollens or molds
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Airway obstruction
A client is undergoing sensitivity testing to define the allergen which is causing the client difficulty. Before the procedure begins, the nurse indicates the various routes in which an allergen can be introduced. What is an allergen introduction route?
All options are correct.
Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States?
All options are correct.
A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times?
An EpiPen
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?
Aplastic anemia
A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?
Are you experiencing fever, chills, or night sweats?
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.
Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions Lung sounds of wheezing Increased respiratory effort
A client reports having diarrhea after every meal. The client has AIDS and wants to know what todo to stop having diarrhea. What should the nurse advise?
Avoid fibrous foods, lactose, fat, and caffeine.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.
Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed?
Candidiasis
Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic?
Check regularly for dependent edema
A client reports taking oral medication for control of sugar problems. Which is the best nursing interpretation of this verbal accounting?
Client has type 2 diabetes mellitus.
What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss?
Consume adequate amounts of fluid
A client sustained a head injury when falling from a ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8-pound weight loss since admission. What condition does the nurse expect the client to be tested for?
Diabetes insipidus (DI)
The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis?
Diarrhea
A patient has been diagnosed with prehypertension and has been encouraged to exercise regularly and begin a weight loss program. What other healthcare professional may be helpful for the client to see?
Dietician
The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?
Eat soft, bland foods and drink cool liquids.
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?
Edema of the upper airway
A nurse is providing information on food allergies to a group of teachers. What food items would the nurse inform the teachers are common allergens?
Eggs and nuts
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.
The nurse is taking the history of a client with diabetes who is experiencing autonomic neuropathy. Which would the nurse expect the client to report?
Erectile dysfunction
The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?
Excessive swallowing
Which of the following is the first barrier method that can be controlled by the woman?
Female condom
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?
Follow the same sexual precautions as someone who has been diagnosed with AIDS.
When teaching a client about hypertension and lifestyle changes what does the nurse emphasizes should be included in the diet?
Fresh fruits and vegetables
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
Fruity breath
The nurse is reviewing a client's history which reveals that the client has had an oversecretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as resulting in which condition?
Gigantism
A client with Addison disease has a blood glucose level above 80 mg/dL 30 minutes after receiving 15 g of carbohydrates for symptoms of hypoglycemia. Which action would the nurse take next?
Give the client milk and graham crackers.
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?
Gynecologic problems
Which of the following precautions would be most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor?
Handle body fluids carefully.
A client with Addison's disease is being discharged from the hospital and is being instructed about the dietary regimen. What type of diet should the nurse provide written and verbal instructions about?
High-protein, moderate-carbohydrate diet
Which is a primary chemical mediator of hypersensitivity?
Histamine
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
Hoarseness for 2 weeks
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Hypocalcemia
A client who suffered blunt chest trauma in a motor vehicle accident reports chest pain during deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. To relieve this chest pain, which position should the nurse encourage the client to assume?
Leaning forward while sitting
Which of the following would the nurse expect the physician to order for a client with hypothyroidism?
Levothyroxine sodium
The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care?
Limiting sodium intake in the diet
Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis?
Maintain the client on bed rest
For a client with Graves' disease, which nursing intervention promotes comfort?
Maintaining room temperature in the low-normal range
A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate?
Neurologic involvement
The nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse?
Notify the physician.
Grace Walters, a 73-year-old female, is a client on the surgical floor where you practice nursing. She is returning from surgical hip repair and has an adhesive patch covering her incision. She has a history of an allergic disorder. Which of the following nursing actions is most important when assessing the dressing site of Mrs. Walters?
Observe Mrs. Walters for signs of allergic reaction.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is thepriority nursing action?
Observe the client's stools for blood.
A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?
Peripheral neuropathy
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?
Postural hypotension
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
Potassium
The period from infection with HIV to the development of antibodies to HIV is known as which of the following?
Primary infection
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?
Reduced sneezing
The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?
Reflects the amount of glucose stored in hemoglobin over past several months.
A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?
Regular
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?
Related to bone demineralization resulting in pathologic fractures
A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?
Rheumatic fever
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize?
Rising slowly from a lying or sitting position
A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing's syndrome (hypercortisolism) and chronic obstructive pulmonary disease, the nurse formulates a nursing diagnosis of:
Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.
A client is taking methimazole (Tapazole) every 8 hours around the clock for the treatment of severe hyperthyroidism. The client has been taking the medication for 2 months. What should the nurse instruct the client to report immediately? Select all that apply.
Sore throat Unusual bleeding Fever
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
Temperature rise
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS.
A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient about this condition?
There could be decreased production of platelets
The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?
They may prolong bleeding
Which group of clients should not receive potassium iodide?
Those who are allergic to seafood
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?
Trauma and microabrasions from a non-electric razor may contribute to anemia.
The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications?
Urinary tract infections
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
Urine output of 15 mL/hour
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis.
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?
dopamine
A client with a significant history of mitral valve prolapse is receiving client education regarding dietary recommendations to compensate for symptoms associated with hypovolemia. Which dietary recommendations would be appropriate?
liberal fluid intake adequate sodium intake
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?
maintaining an open airway
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
profound neuromuscular irritability.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.
semen breast milk blood vaginal secretions
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
It is important for a nurse to refer an HIV-positive client to support groups and resources because:
support groups and resources provide information about new HIV drug development and clinical drug trials to clients
When caring for a client with diabetes insipidus, the nurse expects to administer:
vasopressin.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes.
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
visual disturbances.
A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and:
vitamin D.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
weight.
