Unit 1 test practice NCLEX question

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What are 5 modifiable risk factors

obesity medications (estrogen) diet (decrease fat intake) rapid weight loss dyslipidemia

What are the three adverse effects of alpha adrenergic blockers?

orthostatic hypotension headache dizziness

What are 3 things that contribute to biliary stasis

pregnancy fasting prolonged total parental nutrition

In a DRE, what would be indicative of nodules?

prostate CA

What are the 3 diagnostic tests used to diagnose PUD?

upper GI series gastroscopy H. pylori testing (serum, feces, urea breath test)

After prostate surgery, what could alleviate the burning sensation during urination?

Liberal hydration of 2-3 L of fluids a day

What is TURP syndrome caused by?

absorption of irrigating fluids during and after surgery FLUID VOLUME OVERLOAD

What is the suffix for alpha adrenergic blockers?

-osin

What are 7 lifestyle changes that can help with BPH?

urinate at first urge avoid alcohol/caffeine drink small amounts of fluids throughout the day vs. none avoid drinking fluids 2 hours before bedtime avoid OTC cold medications exercise regularly (kegels) reduce stress

Wha is a normal direct bilirubin level?

0.1 - 0.3 mg/dL

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply. 1. Obtain adequate rest to reduce stimulation. 2. Eat small, frequent meals throughout the day. 3. Take all medications on time as ordered. 4. Sit up for one hour when awakened at night. 5. Stay away from crowded areas.

1, 2, 3, 4. The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (SATA) 1. In this disorder, binge eating occurs exclusively during the course of bulimia nervosa. 2. In this disorder, binge eating occurs, on average, at least once a week for three months. 3. In this disorder, binge eating occurs, on average, at least two days a week for six months. 4. In this disorder, distress regarding binge eating is present. 5. In this disorder, distress regarding binge eating is absent.

1, 3, 5 ~ According to the DSM-5 criteria for the diagnosis of binge-eating disorder, binge eating should not occur exclusively during the course of anorexia nervosa or bulimia nervosa. The new time frame criteria in the DSM-5 states that binge eating must occur, on average, at least once a week for three months not two days a week for six months. The DSM-5 criteria states that distress regarding binge eating would be present.

When caring for a client with a history of BPH what should the nurse do? select all that apply 1. provide privacy and time for the client to void 2. monitor intake and output 3. catheterize the client for postvoid residual urine 4. ask the client if he has urinary retention 5 test the urine for hematuria

1,2,4,5 (because of the HX of BPH, the nurse should provide privacy and time for the client to void. The nurse should also monitor intake and output, assess the client for urinary retention, and test the urine for hematuria. It is not necessary to cath the client)

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? 1. Promptly assess the client for potential perforation. 2. Tell the assistant to change thermometers and retake the temperature. 3. Plan to give the client acetaminophen (Tylenol) to lower the temperature. 4. Ask the assistant to bathe the client with tepid water.

1. A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a physician's order; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery? 1. Encourage the client to ambulate every 2 to 4 hours. 2. Offer 3 to 4 oz of a carbonated beverage periodically. 3. Encourage use of a stool softener. 4. Continue I.V. fluid therapy.

1. Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but will not stimulate peristalsis. A stool softener will not stimulate peristalsis. I.V. fluid infusion is a routine postoperative order that does not have any effect on preventing paralytic ileus.

Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications? 1. Milk, apples, tomatoes, and corn. 2. Eggs, spinach, dried peas, and gravy. 3. Salmon, chicken, caviar, and asparagus. 4. Grapes, corn, cereals, and liver.

1. Because a high-purine diet contributes to the formation of uric acid, a low-purine diet is advocated. An alkaline-ash diet is also advocated because uric acid crystals are more likely to develop in acid urine. Foods that may be eaten as desired in a low-purine diet include milk, all fruits, tomatoes, cereals, and corn. Foods allowed on an alkaline-ash diet include milk, fruits (except cranberries, plums, and prunes), and vegetables (especially legumes and green vegetables). Gravy, chicken, and liver are high in purine.

36. The client with a history of PUD is admitted into the ICU with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output 2. Insert a nasogastric tube and begin saline lavage 3. Assist the client with keeping a detailed calorie count 4. Provide a quiet environment to promote rest

What is the normal flow rate of urine?

14 mL/second

You are admitting a 66-year-old male patient suspected of having a urinary tract infection (UTI). Which piece of the patient's medical history supports this diagnosis? 1. Patient's wife had a UTI 1 month ago 2. Followed for prostate disease for 2 years 3. Intermittent catheterization 6 months ago 4. Kidney stone removal 1 year ago

2 ( Ans: 2 Prostate disease increases the risk of UTIs in men because of urinary retention. The wife's UTI should not affect the patient. The times of the catheter usage and kidney stone removal are too distant to cause this UTI. Focus: Prioritization)

15. The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider 2. Assess the client fo muscle weakness 3. Request telemetry for the client 4. Prepare to administer potassium IV

16. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet 2. Rest the client's bowels 3. Asses vital signs daily 4. Administer antacids orally

20. The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

27. Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Any known allergies to drugs and environmental factors 4. Medical histories of at least three (3) generations

31. Which expected outcome should the nurse include for a client diagnosed with PUD? 1. The client's pain is controlled with the use of NSAIDs 2. The client maintains lifestyle modifications 3. The client has no sign and symptoms of hemoptysis 4. The client takes antacids with each meal

35. Which assessment data would indicate to the nurse that the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response? 1. Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions. 2. Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve. 3. Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support. 4. Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.

2 ~ The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of anorexia nervosa.

The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply. 1. The client has a sore throat. 2. The client has a temperature of 100 ° F (37.8 ° C). 3. The client appears drowsy following the procedure. 4. The client has epigastric pain. 5. The client experiences hematemesis.

2, 4, 5. Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: 1. Involvement with his job will keep the client from becoming bored. 2. A relaxed environment will promote ulcer healing. 3. Not keeping up with his job will increase the client's stress level. 4. Setting limits on the client's behavior is an important nursing responsibility.

2. A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes.

Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate contact sports from his or her lifestyle.

2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

Allopurinol (Zyloprim), 200 mg/ day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which of the following adverse effects of this medication? 1. Retinopathy. 2. Maculopapular rash. 3. Nasal congestion. 4. Dizziness.

2. Allopurinol (Zyloprim) is used to treat renal calculi composed of uric acid. Adverse effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients should be instructed to report rashes and unusual bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not adverse effects of allopurinol.

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? 1. Ineffective coping related to fear of diagnosis of chronic illness. 2. Deficient knowledge related to unfamiliarity with significant signs and symptoms. 3. Constipation related to decreased gastric motility. 4. Imbalanced nutrition: Less than body requirements related to gastric bleeding.

2. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. The data do not support the other diagnoses.

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time? 1. Report hematuria to the physician. 2. Strain the urine carefully. 3. Administer meperidine (Demerol) every 3 hours. 4. Apply warm compresses to the flank area.

2. Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics should be administered when the client needs them, not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened.

The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician? 1. Temperature, 99.8 ° F (37.7 ° C). 2. Urine output, 20 mL/ hour. 3. Absence of bowel sounds. 4. A 2″ × 2″ area of serosanguineous drainage on the flank dressing.

2. The decrease in urine output may reflect inadequate renal perfusion and should be reported immediately. Urine output of 30 mL/ hour or greater is considered acceptable. A slight elevation in temperature is expected after surgery. Peristalsis returns gradually, usually the second or third day after surgery. Bowel sounds will be absent until then. A small amount of serosanguineous drainage is to be expected.

In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for signs of: 1. Nephritis. 2. Referred pain. 3. Urine retention. 4. Additional stone formation.

2. The pain associated with renal colic due to calculi is commonly referred to the groin and bladder in female clients and to the testicles in male clients. Nausea, vomiting, abdominal cramping, and diarrhea may also be present. Nephritis or urine retention is an unlikely cause of the referred pain. The type of pain described in this situation is unlikely to be caused by additional stone formation.

14. The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach 2. Notify the HCP if experiencing a moon face 3. Take the steroid medication as prescribed 4. Notify the HCP if the blood glucose is over 160

When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply. 1. Epigastric pain at night. 2. Relief of epigastric pain after eating. 3. Vomiting. 4. Weight loss. 5. Melena.

3, 4, 5. Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.

30. The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment 2. Assess the client's vital signs frequently 3. Administer a PPI intravenously 4. Obtain permission and administer blood products 5. Monitor the intake of a soft, bland diet

3,4

The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation? 1. Ensuring adequate fluid intake on the day of the test. 2. Preparing the client for the possibility of bladder spasms during the test. 3. Checking the client's history for allergy to iodine. 4. Determining when the client last had a bowel movement.

3. A client scheduled for an IVP should be assessed for allergies to iodine and shellfish. Clients with such allergies may be allergic to the IVP dye and be at risk for an anaphylactic reaction. Adequate fluid intake is important after the examination. Bladder spasms are not common during an IVP. Bowel preparation is important before an IVP to allow visualization of the ureters and bladder, but checking for allergies is most important.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? 1. Bland foods. 2. High-protein foods. 3. Any foods that are tolerated. 4. Large amounts of milk.

3. Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? 1. The client has not been including enough fiber in his diet. 2. The client needs to increase his daily exercise. 3. The client is experiencing an adverse effect of the aluminum hydroxide. 4. The client has developed a gastrointestinal obstruction.

3. It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? 1. Before meals. 2. With meals. 3. At bedtime. 4. When pain occurs.

3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time? 1. Altered nutrition less than body requirements 2. Altered social interaction 3. Impaired verbal communication 4. Altered family processes

4 ~ The nurse should determine that once the client has been medically cleared, the diagnosis of altered family process should take priority. Clients diagnosed with anorexia nervosa have a need to control and feel in charge of their own treatment choices. Behavioral-modification therapy allows the client to maintain control of eating.

A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug? 1. Heal the ulcer. 2. Protect the ulcer surface from acids. 3. Reduce acid concentration. 4. Limit gastric acid secretion.

4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretory, or proton-pump inhibitors, such as omeprazole (Prilosec), help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate (Carafate), protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? 1. Do not allow the client to ingest fluids. 2. Encourage the client to drink at least 500 mL of water each hour. 3. Request the central supply department to send supplies for straining urine. 4. Administer an opioid analgesic as prescribed.

4. If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? 1. Conduct physical activity in the morning so that he can rest in the afternoon. 2. Have the family agree to perform the necessary yard work at home. 3. Give up jogging and substitute a less demanding hobby. 4. Incorporate periods of physical and mental rest in his daily schedule.

4. It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? 1. An intestinal obstruction has developed. 2. Additional ulcers have developed. 3. The esophagus has become inflamed. 4. The ulcer has perforated.

4. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigastric pain. The development of additional ulcers or esophageal inflammation would not cause a rigid, boardlike abdomen.

A nurse teaches a client experiencing heartburn to take 1 ½ oz of Maalox when symptoms appear. How many milliliters should the client take? ________________________ mL. .

45 mL

A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to the hospital the morning of surgery. He is accompanied by his wife but does not talk to her and does not initiate interaction with the nurse. The most appropriate action by the nurse is to a. ask the patient if he has any questions or concerns about the diagnosis and treatment. b. tell the patient's wife that concerns about sexual function are common with this diagnosis. c. teach the patient that impotence is rarely a problem after unilateral orchiectomy. d. document the patient's lack of communication on the chart and continue preoperative care.

What is a normal indirect bilirubin level?

<1.1 mg/dL

A 53-year-old man tells the nurse he has not been able to function sexually for several years but is now interested in using Viagra (sildenafil). In responding to the patient's interest, the nurse a. questions the patient about any prescription drugs he is taking. b. tells the patient that Viagra is an appropriate treatment for only a few types of ED. c. asks the patient about any previous treatment for hydrocele. d. reassures the patient that a gradual decline in erectile function is common with aging.

A client experiencing an acute episode of renal colic rates the pain at a 9 on a scale of 0-10. Which prescribed treatment should the nurse anticipate? (Select all that apply.) A) Morphine B) Indomethacin C) Thiazide diuretic D) Potassium citrate

A, B Rationale: In an acute episode of renal colic, morphine is prescribed. Morphine is a narcotic analgesic given intravenously to relieve pain and reduce ureteral spasms. Indomethacin is an NSAID, given as a suppository that may reduce the amount of narcotic analgesic required for acute renal colic. A thiazide diuretic is frequently prescribed for calcium calculi, acts to reduce urinary calcium excretion, and is very effective in preventing further stones. Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones).

The nurse is providing a session on goal planning for clients with a personality disorder (PD). Which statement should be a part of this plan? (Select all that apply.) A) The client will remain free from self-harm. B) The client will report a reduction in anxiety. C) The client will not exhibit violent behaviors. D) The client will discontinue medications if the side effects are overwhelming. E) The client will take all medications in the morning to prevent insomnia.

A, B, C Rationale: Client goals are measurable, specific outcomes that allow for evaluation of the efficacy of nursing interventions. Goals of care should be realistic and tailored to the client. Remaining free from injury and free from self-harm, refraining from violent behaviors, and reporting a reduction in anxiety are appropriate for this plan. Medications should be taken according to the prescribed requirements.

A client with mild benign prostatic hyperplasia (BPH) tells the nurse that he prefers to do things "naturally" and doesn't want to take medication for his condition. Which lifestyle change should the nurse recommend? (Select all that apply.) A) Reducing stress B) Avoiding alcohol and caffeine C) Avoiding drinking fluids within 2 hours of bedtime D) Exercising regularly, including pelvic floor exercises E) Increasing dietary intake of foods high in potassium

A, B, C, D Rationale: Lifestyle changes that may help clients with mild BPH include avoiding alcohol and caffeine; exercising regularly, including Kegel exercises; avoiding drinking fluids within 2 hours of bedtime; and reducing stress. Dietary intake of potassium is not related to BPH symptoms.

A client is brought to the emergency department after being found unconscious by her daughter. The daughter reports that her mother has been struggling with eating disorders for "as long as I can remember" and has been in and out of treatment programs for bulimia nervosa. Which test should the nurse expect the healthcare provider to order? (Select all that apply.) A) Urinalysis B) Electrocardiography (ECG) C) Blood glucose monitoring D) Computerized tomography (CT) scan E) Comprehensive metabolic panel (CMP)

A, B, C, E Rationale: Electrolyte imbalances are common in clients with eating disorders. A CMP is necessary to learn whether serum potassium is decreased, which could cause cardiac arrhythmias. Blood glucose monitoring may indicate hypoglycemia or diabetic ketoacidosis if the client is purging or diabetic. Electrocardiography is used to detect any cardiac arrhythmias resulting from electrolyte imbalances; some arrhythmias associated with eating disorders are fatal. Urinalysis indicates the presence of ketones. A CT scan is not indicated for clients with eating disorders.

The nurse is providing discharge instructions to a postoperative client who is being discharged home with an indwelling urinary catheter. Which information should the nurse include in discharge teaching? (Select all that apply.) A) Empty the leg bag every 3-4 hours. B) Avoid strapping on the leg bag too tightly. C) Place powder around the bag to prevent odor. D) Place a soft cloth between the leg bag and thigh. E.) Change from a daytime leg bag to a larger drainage bag at night.

A, B, D, E Rationale: Changing to a larger bag at night permits gravity drainage and keeps urine from backing up in the bladder. If the leg bag is strapped on too tightly, it can impede venous return in the leg. Placing a soft cloth between the bag and the thigh protects the skin and absorbs any wetness. Emptying the leg bag every 3-4 hours prevents overfilling. Powder is not indicated. If there is a strong urine smell, this should be reported to the urologist, along with changes in urine color, urine consistency and amount, hematuria, frank bleeding, or large blood clots.

The nurse caring for a client 24-hours post-transurethral resection of the prostate (TURP) should assess for which complication? (Select all that apply.) A) Hemorrhage B) Hypotension C) Hypertension D) Large blood clots E) Decreased urinary output

A, B, D, E Rationale: During the first 24-48 hours after a TURP, the client should be monitored closely for hemorrhage (frank bloody urine output), the presence of large blood clots, decreased urinary output, increased bladder spasms, decreased hemoglobin and hematocrit, tachycardia, and hypotension. Hypertension would not be an expected complication.

A client is experiencing acute hydronephrosis. Which prescribed clinical therapy should the nurse expect will be initiated? (Select all that apply.) A) IV therapy B) Oral hydration C) Thiazide diuretic D) Calcium-binding agents

A, C Rationale: Acute hydronephrosis is caused by the development of a sudden obstruction of urine flow. Prescribed clinical treatment includes IV therapy. A thiazide diuretic and calcium-binding agent are only administered if the stone is caused by excess calcium. Oral hydration is implemented in chronic hydronephrosis caused by gradual development of obstruction of urine flow.

A client presents at the urgent care clinic and states, "My heart feels like it's skipping beats." The client also reports always feeling cold, and has a BMI of 18. The nurse suspects anorexia. Which other clinical manifestation should the nurse assess? (Select all that apply.) A) Strenuous exercise B) Feelings of euphoria C) Extreme perfectionism D) Obsession over body shape E) Rigidity and the need to control situations

A, C, D, E Rationale: Clinical manifestations of anorexia nervosa include obsession with body shape; obsession with food; extreme perfectionism; rigidity and the need to control situations; and over-exercise. Depression, not euphoria, is also a common manifestation

Which statement should the nurse include in a presentation regarding eating disorders? (Select all that apply.) A) Eating disorders can cause malnutrition. B) Teenagers are the only age group with eating disorders. C) Excessive exercise can be associated with an eating disorder. D) Diet pills and laxatives are not used by people with eating disorders. E) Electrolyte imbalance is a common problem associated with eating disorders.

A, C, E Rationale: Eating disorders occur across the lifespan; although it is often thought that only adolescents have eating disorders, women in their 50s, 60s, and 70s are also at risk. Some clients use diet pills, laxatives, and excessive exercise to obsessively control their weight. Electrolyte imbalance and malnutrition are problems commonly associated with eating disorders.

The primary goal of milieu therapy for clients with personality disorders is A. manage the affect behavior has on the entire group. B. one-on-one therapy. C. to help the client remain uninvolved with other patients. D. a laissez faire attitude.

A. manage the affect behavior has on the entire group. The primary goal of milieu therapy is affect management in a group context

A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, You used to care about me. I thought you were wonderful. Now I can see I was mistaken. Youre terrible. This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

B ~ Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver.

The nurse is preparing a client for surgery for benign prostatic hyperplasia (BPH). Which clinical manifestations should the nurse expect in the client's history and physical that would support the need for surgery? (Select all that apply.) A) Nocturia B) Hematuria C) Bladder stones D) Urinary retention E) Renal insufficiency secondary to BPH

B, C, D, E Rationale: Candidates for prostate surgery are clients who have urinary retention, hematuria, bladder stones, and renal insufficiency secondary to BPH. Nocturia alone is not a reason to undergo surgery.

The nurse is providing a training session about the safety of clients with a personality disorder (PD) to a group of new nurses. Which strategy should the nurse include in the lecture? (Select all that apply.) A) Restraints B) Close supervision C) Behavioral contracts D) Addressing impulsive behavior E) Closely checking their environment

B, C, D, E Rationale: For clients with PDs, some of whom are prone to self-destructive and impulsive behavior, the emphasis on injury prevention is heightened. Behavioral contracts that outline prohibited actions and the consequences of those actions may be used to establish clear guidelines and expectations with regard to any form of behavior, including that related to injuring self or others. Basic precautions for clients in hospital settings include ensuring that the client's environment is free from items that may be used to harm self or others and providing close supervision and monitoring. Restraints are only used as a last resort.

While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.

C ~ Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

Splitting is a process in which the client A. unconsciously represses undesirable aspects of self. B. places responsibility for his or her behavior outside the self. C. sees things as divided into "all good" or "all bad." D. evidences lack of personal boundaries.

C. sees things as divided into "all good" or "all bad." Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad.

The nurse is preparing a seminar on methods to decrease risk factors for personality disorders. Which resource should the nurse include in the presentation? (Select all that apply.) A) YMCA B) The Boys and Girls Club C) Incredible Years Program D) New Beginnings Program E) The Nurse-Family Partnership Program

C, D, E Rationale: Resources that are appropriate for the nurse to include in the presentation are The Nurse-Family Partnership Program, Incredible Years Program, and New Beginnings Program. Developing skills and interacting with others are essential components of preventive organizations. The Boys and Girls Club and the YMCA have not been identified as resources for decreasing risk factors for developing PD and should not be included in the presentation.

In addition to the goal of validating a client's behaviors and actions, which is a focus in dialectical behavioral therapy (DBT)? (Select all that apply.) A) Self-efficacy B) Direct interactions C) Validated problems D) Pointing out unhealthy patterns E) Teaching emotional self-regulation

D, E Rationale: A combination of cognitive and behavior therapy, DBT originally was developed to treat clients with suicidal thoughts. DBT refers to striking a balance between two extremes; the therapist displays understanding and validates the client's behaviors and feelings while at the same time imposing limits and making the client responsible for changing unhealthy patterns. DBT also teaches clients emotional regulation and distress tolerance. It has proven effective in treating borderline personality disorder, showing lower dropout rates than other therapies and decreasing the frequency of suicide attempts.

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that A. Shock-wave therapy should be tried initially. B. Once gallstones are removed, they tend not to recur. C. The disorder can be successfully treated with oral bile salts that dissolve gallstones. D. Laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic

D. Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? A. The child is fearful of the caregiver and other adults. B. The child has a lack of peer relationships.. C. The child has self-injurious behavior. D. The child has interest in things of a sexual nature

D. The child has interest in things of a sexual nature

Inflammation of the gallbladder

cholecystitis

What race is most affected by kidney stones

whites

The nurse admits a hypertensive client diagnosed with glomerulonephritis. Which medication should the nurse expect to be ordered for the client? Angiotensin-converting enzyme (ACE) inhibitor Antibiotic Glucocorticoid Beta blocker

Angiotensin-converting enzyme (ACE) inhibitor ACE inhibitors or angiotensin receptor blockers (ARBs) are the first choice for antihypertensive agents in glomerulonephritis. These medications slow the progression of renal failure. They also reduce protein loss associated with nephrotic syndrome. Beta blockers are not indicated in glomerulonephritis; they are used to reduce hypertension and cardiac workload. Antibiotics are used to treat infections and glucocorticoids reduce inflammation.

What is the suffix for alpha reductase inhibitors

-asteride

What is a normal total bilirubin level?

0.1 - 1.2 mg/dL

In regards to a patient's weight, how much urine should they pass per hour?

0.5 mL/kg/hr

13. Which sign/symptoms should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day 2. Oral temperature of 102 degrees Fahrenheit 3. Hard, rigid abdomen 4. Urinary stress incontinence

17. The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level 2. Administer an oral hypoglycemic 3. Assess the peripheral intravenous site 4. Monitor the client's oral food intake

22. The client diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports thing diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

24. The client with ulcerative colitis is scheduled for an ileostomy. The nurse is aware the client's stoma will be located in which area of the abdomen? 1. R Iliac region 2. L Iliac region 3. Epigastric region 4. R Hypochondriac region

26. The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy 2. Magnetic resonance imaging 3. Occult blood test 4. Gastric acid stimulation

28. Which physical examination should the nurse implement first when assessing the client diagnosed with PUD? 1. Auscultate the client's bowel sounds in all four quadrants 2. Palpate the abdominal area for tenderness 3. Percuss the abdominal borders to identify organs 4. Assess the tender area progressing to nontender

33. Which oral medication should the nurse question before administering to the client with PUD? 1. E-mycin, an antibiotic 2. Prilosec, a PPI 3. Flagyl, an antimicrobial agent 4. Tylenol, a nonnarcotic analgesic

An adult male client has been unable to void for the past 12 hours. The BEST method for the nurse to use when assessing for bladder distension in a male client is to check for: 1 a rounded swelling above the pubis 2 dullness in the LLQ 3 rebound tenderness below the symphysis 4 urine discharge from urethral meatus

The primary reason for taping an indwelling catheter laterally to the thigh of a male client is to : 1 eliminate pressure to the penoscrotal angle 2 prevent the catheter from kinking in the urethra 3 prevent accidental catheter removal 4 allow the client to turn without kinking the catheter

1 (prolonged pressure at the penoscrotal angle can cause a ureterocutaneous fistula)

You are supervising a senior nursing student who is caring for a 78-year-old scheduled for an intravenous pyelography. What information would you be sure to stress about this procedure to the nursing student? 1. "After the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults." 2. "The purpose of this procedure is to measure kidney size." 3. "Because this procedure assesses kidney function, there is no need for a bowel prep." 4. "Keep the patient NPO after the procedure because during the procedure the patient will receive drugs that affect the gag reflex."

1 (The risk for contrast-induced kidney failure is greatest in patients who are older or dehydrated. If possible, arrange for the patient to have this procedure early in the day to prevent dehydration. The purpose of this procedure is to assess kidney function and identify anomalies. The administration of drugs that affect the gag reflex is not done during this procedure. Focus: Supervision, prioritization)

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (SATA) 1. Binge eating with a diagnosis of obesity 2. Bingeing and purging with a diagnosis of bulimia nervosa 3. Weight loss with a diagnosis of anorexia nervosa 4. Amenorrhea with a diagnosis of anorexia nervosa 5. Emaciation with a diagnosis of bulimia nervosa

1, 2 ~ The nurse should identify that topiramate is the drug of choice when treating binge eating with a diagnosis of obesity or bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight.

The nurse is reviewing the med history of a client with BPH. Which medication will likely aggravate BPH? 1. metformin 2. buspirone 3. inhaled ipratropium 4. ophthalmic timolol

3 (ipratropium is a bronchodilator, and its anticholinergic effects can aggravate urine retention.)

In a male patient who must undergo intermittent catheterization, you are preparing to insert a catheter to assess the patient for postvoid residual. Place the steps for catheterization in the correct order. 1. Assist the patient to the bathroom and ask the patient to attempt to void. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 3. Open the catheterization kit and put on sterile gloves. 4. Lubricate the catheter and insert it through the meatus of the penis. 5. Position the patient supine in bed or with the head slightly elevated. 6. Drain all the urine present in the bladder into a container. 7. Cleanse the glans penis starting at the meatus and working outward. 8. Remove the catheter, clean the penis, and measure the amount of urine returned. ____, ____, _____, _____, ____, ____, _____, _____

1 5 3 2 7 4 6 8 (Before checking postvoid residual, you should ask the patient to void, and then position him. Next you should open the catheterization kit and put on sterile gloves, position the patient's penis, clean the meatus, then lubricate and insert the catheter. All urine must be drained from the bladder to assess the amount of postvoid residual the patient has. Finally, the catheter is removed, the penis cleaned, and the urine measured. Focus: Prioritization)

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? 1. Being firm, consistent, and empathic, while addressing specific client behaviors 2. Promoting client self-expression by implementing laissez-faire leadership 3. Using authoritative leadership to help clients learn to conform to society norms 4. Overlooking inappropriate behaviors to avoid providing secondary gains

1 ~ The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

Family members of a client ask the nurse to explain the difference between schizoid & avoidant personality disorders. Which is the appropriate nursing response? 1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. 2. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not. 3. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. 4. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

1 ~ The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder may exhibit odd and eccentric behaviors but not to the extent of psychosis.

A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide? 1. The emesis produced during purging is acidic and corrodes the tooth enamel. 2. Purging causes the depletion of dietary calcium. 3. Food is rapidly ingested without proper mastication. 4. Poor dental and oral hygiene leads to dental caries.

1 ~ The nurse should explain to the client diagnosed with bulimia nervosa that her teeth will eventually deteriorate, because the emesis produced during purging is acidic and corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication? 1. Phentermine (Mirapront) 2. Dexfenfluramine (Redux) 3. Sibutramine (Meridia) 4. Pemoline (Cylert)

1 ~ The nurse should teach the client that phentermine is an anorexiant medication prescribed for morbidly obese clients. Phentermine works on the hypothalamus to stimulate the adrenal glands to release norepinephrine, a neurotransmitter that signals a fight-or-flight response, reducing hunger. Dexfenfluramine has been removed from the market because of its association with serious heart and lung disease. Several deaths have been associated with the use of sibutramine by high-risk clients. Based on pressure from the FDA, the manufacturer issued a recall of the drug in October 2010. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? 1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

1 ~ The nurse should understand that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia do not. Anorexia is characterized by a morbid fear of obesity and often results in low caloric and nutritional intake. Bulimia is characterized by episodic, rapid consumption of large quantities of food followed by purging.

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder? 1. Risk for violence: directed toward others R/T paranoid thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others

1 ~ The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T paranoid thinking. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness. They are often tense and irritable, which increases the likelihood of violent behavior.

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (SATA) 1. The client will relate one empathetic statement to another client in group by day two. 2. The client will identify one personal limitation by day one. 3. The client will acknowledge one strength that another client possesses by day two. 4. The client will list four personal strengths by day three. 5. The client will list two lifetime achievements by discharge.

1, 2, 3 ~ The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. Narcissistic personality disorder is characterized by an exaggerated sense of self-worth, a lack of empathy, and exploitation of others.

A client is being assessed for antisocial personality disorder. According to the DSM-5, which of the following symptoms must the client meet in order to be assigned this diagnosis? (SATA) 1. Ego-centrism and goal setting based on personal gratification. 2. Incapacity for mutually intimate relationships. 3. Frequent feelings of being down miserable and/or hopeless. 4. Disregard for and failure to honor financial and other obligations. 5, Intense feelings of nervousness, tenseness, or panic.

1, 2, 4 ~ The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. Pathological personality traits of antagonism and disinhibition must occur in order to meet the criteria for the diagnosis of antisocial personality disorder. Frequent feelings of being down, miserable, and/or hopeless and intense feelings of nervousness, tenseness, or panic are characteristics of the pathological personality trait domain of negative affectivity. This domain is listed by the DSM-5 for the diagnosis of borderline personality disorder, not antisocial personality disorder.

A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect( s) of this drug? Select all that apply. 1. Nausea. 2. Rash. 3. Constipation. 4. Flushed skin. 5. Bone marrow depression.

1, 2, 5. Common adverse effects of allopurinol (Zyloprim) include gastrointestinal distress, such as anorexia, nausea, vomiting, and diarrhea. A rash is another potential adverse effect. A potentially life-threatening adverse effect is bone marrow depression. Constipation and flushed skin are not associated with this drug.

Which of the following would contribute to a clients excessive weight gain? (SATA) 1. A hypothalamus lesion 2. Hyperthyroidism 3. Diabetes mellitus 4. Cushings disease 5. Low levels of serotonin

1, 3, 4 ~ Lesions in the appetite and satiety centers in the hypothalamus may contribute to overeating and lead to obesity. Hypothyroidism, not hyperthyroidism, is a problem that interferes with basal metabolism and may lead to weight gain. Weight gain can also occur in response to the decreased insulin production of diabetes mellitus and the increased cortisone production of Cushing's disease. New evidence also exists to indicate that low levels of the neurotransmitter serotonin may play a role in compulsive eating.

A nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this clients care? (SATA) 1. This client has personality traits that are deeply ingrained and difficult to modify. 2. This client needs medication to treat the underlying physiological pathology. 3. This client uses manipulation, making the implementation of treatment problematic. 4. This client has poor impulse control that hinders compliance with a plan of care. 5. This client is likely to have secondary diagnoses of substance abuse and depression.

1, 3, 4, 5 ~ The nurse should consider that individuals diagnosed with antisocial personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse or depression.

A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (SATA) 1. The client has been diagnosed with sickle cell anemia. 2. The client has an inflated self-appraisal and feels a sense of entitlement. 3. The client has a history of a substance use disorder. 4. The client is odd and eccentric but not delusional. 5. The client has an intellectual developmental disorder.

1, 3, 5 ~ The DSM-5 states that impairments in personality functioning and the individuals personality trait expression are not better understood as normative for the individuals developmental stage or sociocultural environment. The impairments in personality functioning and the individuals personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). The nurse would question the diagnosis of a personality disorder in a client with sickle cell anemia, substance use disorder, or an intellectual developmental disorder.

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? 1. Increase daily fluid intake to at least 2 to 3 L. 2. Strain urine at home regularly. 3. Eliminate dairy products from the diet. 4. Follow measures to alkalinize the urine.

1. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

The nurse caring for a client with uncomplicated cholelithiasis anticipates that the client's laboratory test results will show an elevation in which of the following? 1. Serum amylase 2. Alkaline phosphatase 3. Mean corpuscular hemoglobin concentration (MCHC) 4. Indirect bilirubin

Answer: 2 Rationale: Obstructive biliary disease causes a significant elevation in alkaline phosphatase.

What urine flow rate indicates a problem?

10 mL/second

You are caring for a client who has just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? 1. Blood pressure reading of 153/88 mm Hg 2. Catheter that is draining deep red blood 3. Client not wearing antiembolism hose 4. Client reports of abdominal cramping

2 (Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately. The other assessment data also indicate a need for nursing action, but not as urgently. Focus: Prioritization)

The nurse should specifically assess the client with BPH for: 1. voiding at less frequent intervals 2. difficulty starting the flow of urine 3. painful urination 4. increased force in the urine stream

2 (S/S of BPH include difficulty starting flow of urine, urinary frequency and hesitancy, decreased force of urine stream, interruptions in the urine stream when voiding and nocturia. The prostate gland surrounds the urethra, and these symptoms are attributed to obstruction of the urethra resulting from BPH. Nocturia is common. Straining and urine retention are usually the symptoms that prompt the client to seek care.)

A 79-year-old who has just returned to the surgical unit following a TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? 1. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. 2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL daily. _____, _____, _____, _____

2 1 3 4 (Bladder spasms after a TURP are usually caused by the presence of clots that obstruct the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate postoperative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged once you are sure that the client is not nauseated and has adequate bowel tone. Focus: Prioritization)

What combination of medications is used to eradicate H. pylori?

2 antibiotics and 1 PPI

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior? 1. You are very disrespectful. You need to learn to control yourself. 2. I understand that you are angry, but this behavior will not be tolerated. 3. What behaviors could you modify to improve this situation? 4. What anti-personality disorder medications have helped you in the past?

2 ~ The appropriate nursing response is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism.

A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility & has a behavioral pattern of suffering in silence. Which statement best explains the etiology of this clients personality disorder? 1. Childhood nurturance was provided from many sources, and independent behaviors were encouraged. 2. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged. 3. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged. 4. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

2 ~ The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source & discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective & discourages autonomy.

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? 1. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. 2. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. 3. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. 4. They pay particular attention to details, which can interfere with the development of relationships.

2 ~ The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having relationships that are shallow and fleeting. These types of relationships tend to serve their dependency needs.

From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder? 1. Seclude the client when inappropriate behaviors are exhibited. 2. Contract with the client to reinforce positive behaviors with unit privileges. 3. Teach the purpose of anti-anxiety medications to improve medication compliance. 4. Encourage the client to journal feelings to improve awareness of abandonment issues.

2 ~ The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

A highly emotional client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a sance." Which personality disorder should a nurse associate with this behavior? 1. Obsessive-compulsive personality disorder 2. Schizotypal personality disorder 3. Narcissistic personality disorder 4. Borderline personality disorder

2 ~ The nurse should associate schizotypal personality disorder with this behavior. The behaviors of people diagnosed with schizotypal personality disorder are odd and eccentric but do not decompensate to the level of schizophrenia.

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? 1. The use of highly lethal methods to commit suicide 2. The use of suicidal gestures to elicit a rescue response from others 3. The use of isolation and starvation as suicidal methods 4. The use of self-mutilation to decrease endorphins in the body

2 ~ The nurse should expect that a client diagnosed with borderline personality disorder may use suicidal gestures to elicit a rescue response from others. Repetitive, self-mutilating behaviors are common in borderline personality disorders that result from feelings of abandonment following separation from significant others.

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? 1. A client diagnosed with antisocial personality disorder 2. A client diagnosed with borderline personality disorder 3. A client diagnosed with schizoid personality disorder 4. A client diagnosed with paranoid personality disorder

2 ~ The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilating behaviors. Most gestures are designed to elicit a rescue response.

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? 1. Allow the clients to apply the democratic process when developing unit rules. 2. Maintain consistency of care by open communication to avoid staff manipulation. 3. Allow the client spokesman to verbalize concerns during a unit staff meeting. 4. Maintain unit order by the application of autocratic leadership.

2 ~ The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. 1. Administering an antacid hourly until nausea subsides. 2. Monitoring the client's vital signs. 3. Notifying the physician of the client's symptoms. 4. Initiating oxygen therapy. 5. Reassessing the client in an hour.

2, 3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the physician of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.

After an intravenous pyelogram (IVP), the nurse should anticipate incorporating which of the following measures into the client's plan of care? 1. Maintaining bed rest. 2. Encouraging adequate fluid intake. 3. Assessing for hematuria. 4. Administering a laxative.

2. After an IVP, the nurse should encourage fluids to decrease the risk of renal complications caused by the contrast agent. There is no need to place the client on bed rest or administer a laxative. An IVP would not cause hematuria.

Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic? 1. Applying moist heat to the flank area. 2. Administering meperidine (Demerol). 3. Encouraging high fluid intake. 4. Maintaining complete bed rest.

2. During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics to control the pain. Application of heat, encouraging high fluid intake, and limitation of activity are important interventions, but they will not relieve the renal colic pain.

A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to: 1. Irrigate the catheter with 30 mL of normal saline every 8 hours. 2. Ensure that the catheter is draining freely. 3. Clamp the catheter every 2 hours for 30 minutes. 4. Ensure that the catheter drains at least 30 mL/ hour.

2. The ureteral catheter should drain freely without bleeding at the site. The catheter is rarely irrigated, and any irrigation would be done by the physician. The catheter is never clamped. The client's total urine output (ureteral catheter plus voiding or indwelling urinary catheter output) should be 30 mL/ hour.

18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart 2. Teach coping strategies such as dietary modifications 3. Record the frequency, amount, and color of stools 4. Monitor the client's oral fluid intake every shift

19. 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? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

23. The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried ﬁsh, whole grain pasta, and fruit salad.

32. The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. When the nurse is evaluating care, which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

When emptying the clients bladder during a urinary catheterization, the nurse should allow the urine to drain from the bladder slowly to prevent: 1. renal failure 2. abdominal cramping 3. possible shock 4 atrophy of bladder musculature

Looking at a slightly bleeding paper cut, the client screams, Somebody help me quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder? 1. Schizoid personality disorder 2. Obsessive-compulsive personality disorder 3. Histrionic personality disorder 4. Paranoid personality disorder

3 ~ The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago.

3 (A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization)

A client with BPH is being treated with terazosin 2 mg at bedtime. The nurse should monitor the client for: 1 urine nitrites 2 WBC count 3 blood pressure 4 pulse

3 (Terazosin is an antihypertensive drug that is also used to treat BPH. BP must be monitored to ensure the client does not develop hypotension, syncope, or orthostatic hypotension. Inform the client to change positions slowly)

Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder? 1. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications. 2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety. 3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis. 4. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis.

3 ~ A client diagnosed with schizoid personality disorder exhibits a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder prefer being alone to being with others and avoid social situations, social contacts, and activities.

Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? 1. A physically healthy client who is dependent on meeting social needs by contact with 15 cats 2. A physically healthy client who has a history of depending on intense relationships to meet basic needs 3. A physically healthy client who lives with parents & depends on public transportation 4. A physically healthy client who is serious, inflexible, perfectionistic, lacks spontaneity & depends on rules to provide security

3 ~ A physically healthy adult client who lives with parents and depends on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors.

When planning care for clients diagnosed with personality disorders, what should be the goal of treatment? 1. To stabilize the clients pathology by using the correct combination of psychotropic medications 2. To change the characteristics of the dysfunctional personality 3. To reduce personality trait inflexibility that interferes with functioning and relationships 4. To decrease the prevalence of neurotransmitters at receptor sites

3 ~ The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. There are no psychotropic medications approved specifically for the treatment of personality disorders.

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? 1. Provide objective evidence that reasons for violence are unwarranted. 2. Initially restrain the client to maintain safety. 3. Use clear, calm statements and a confident physical stance. 4. Empathize with the clients paranoid perceptions.

3 ~ The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate? 1. Go ahead and use the phone. I know this pending divorce is stressful. 2. You know better than to break the rules. I'm surprised at you. 3. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. 4. A divorce shouldn't be considered until you have had a good nights sleep.

3 ~ The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client's home environment should a nurse associate with the development of anorexia nervosa? 1. The home environment maintains loose personal boundaries. 2. The home environment places an overemphasis on food. 3. The home environment is overprotective and demands perfection. 4. The home environment condones corporal punishment.

3 ~ The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against the parents viewed by the child as a means of gaining and remaining in control.

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? 1. Interpreting the compliment as a secret code used to increase personal power 2. Feeling the compliment was well deserved 3. Being grateful for the compliment but fearing later rejection and humiliation 4. Wondering what deep meaning and purpose is attached to the compliment

3 ~ The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1. The client gained two pounds in one week. 2. The client focused conversations on nutritious food. 3. The client demonstrated healthy coping mechanisms that decreased anxiety. 4. The client verbalized an understanding of the etiology of the disorder.

3 ~ The nurse should identify that a client who demonstrates healthy coping mechanisms to decrease anxiety indicates a positive behavioral change. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behavior.

A client's altered body image is evidenced by claims of feeling fat, even though the client is emaciated. Which is the appropriate outcome criterion for this clients problem? 1. The client will consume adequate calories to sustain normal weight. 2. The client will cease strenuous exercise programs. 3. The client will perceive personal ideal body weight and shape as normal. 4. The client will not express a preoccupation with food.

3 ~ The nurse should identify that the appropriate outcome for this client is to perceive personal ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? 1. The client experiences unwanted, intrusive, and persistent thoughts. 2. The client experiences unwanted, repetitive behavior patterns. 3. The client experiences inflexibility and lack of spontaneity when dealing with others. 4. The client experiences obsessive thoughts that are externally imposed.

3 ~ The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? 1. The client awaiting hiatal hernia repair at 11 am. 2. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests. 3. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain. 4. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.

3, 4, 2, 1 The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6 ° F (38.1 ° C). Which of the following would be a priority outcome for this client? 1. Prevention of urinary tract complications. 2. Alleviation of nausea. 3. Alleviation of pain. 4. Maintenance of fluid and electrolyte balance.

3. The priority nursing goal for this client is to alleviate the pain, which can be excruciating. Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the client's hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid and electrolyte imbalance.

The client returning from a colonoscopy has been give a diagnosis of Crohn's disease. The nurse expects to note which manifestations i the client? SATA A. Steatorrhea B. Firm, rigid abdomen C. Constipation D. Enlarged hemorrhoids E. Diarrhea

A. Steatorrhea E. Diarrhea Steatorrhea is often present in the client with Crohn's Disease. Diarrhea is a key feature, but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less frequent in number of episodes.

21 . The client diagnosed with IBD is prescribed sulfasalazine (Asulﬁdine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inﬂammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inﬂammation.

25. Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month 2. Reports of a burning sensation moving like a wave 3. Sharp pain int he upper abdomen after eating a heavy meal 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food

29. Which problems should the nurse include in the plan of care for the client diagnosed with PUD to observe for physiological complications? 1. Alteration in bowel elimination patterns 2. Knowledge deficit in the causes of ulcers 3. Inability to cope with changing family roles 4. Potential for alteration in gastric emptying

34. The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse that the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Post-operatvely, the nurse should assess the client for: 1 seizures 2 cardiac arrest 3 renal shutdown 4 respiratory paralysis

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder? 1. Skaters need to be thin to improve their daily performance. 2. All the skaters on the team are following an approved 1200-calorie diet. 3. The exercise of skating reduces my appetite but improves my energy level. 4. I am angry at my mother. I can only get her approval when I win competitions.

4 ~ The client reflects insight when referring to feelings toward family dynamics that may have influenced the development of the disease. Families who are overprotective and perfectionistic can contribute to the development of anorexia nervosa.

A 67-year-old client with BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client? 1. "This medication will improve your symptoms by shrinking the prostate." 2. "The force of your urinary stream will probably increase." 3. "Your blood pressure will decrease as a result of taking this medication." 4. "You should avoid sitting up or standing up too quickly

4 (Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change positions slowly. The other information is also accurate and may be included in client teaching but is not as important as decreasing the risk for falls. Focus: Prioritization)

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? 1. Altered thought processes R/T increased stress 2. Risk for suicide R/T loneliness 3. Risk for violence: directed toward others R/T paranoid thinking 4. Social isolation R/T inability to relate to others

4 ~ An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof & indifferent to others. They prefer to work in isolation & are not sociable.

A nurse is teaching a client diagnosed with an eating disorder about behavior-modification programs. Why is this intervention the treatment of choice? 1. It helps the client correct a distorted body image. 2. It addresses the underlying client anger. 3. It manages the client's uncontrollable behaviors. 4. It allows clients to maintain control.

4 ~ Behavior-modification programs are the treatment of choice for clients diagnosed with eating disorders, because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques function to restore healthy weight.

Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder? 1. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. 2. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you don't stay with me. 3. As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please don't go! I can't sleep without you being here. 4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me.

4 ~ The client who states, I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others.

During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder? 1. I don't have a problem. My family is inflexible, and relatives are out to get me. 2. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses? 3. I spend all my time tending my bees. I know a whole lot of information about bees. 4. I am getting a message from the beyond that we have been involved with each other in a previous life.

4 ~ The nurse should assess that a client who states that she is getting a message from beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof & isolated & behave in a bland & apathetic manner. The person experiences magical thinking, ideas of reference, illusions & depersonalization as part of daily life.

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? 1. You really don't have to go by that schedule. I'd just stay home sick. 2. There has got to be a hidden agenda behind this schedule change. 3. Who do you think you are? I expect to interact with the same nurse every Saturday. 4. You can't make these kinds of changes! Isn't there a rule that governs this decision?

4 ~ The nurse should identify that a client with obsessive-compulsive personality disorder would have a difficult time accepting changes. This disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder? 1. Risk for violence: directed toward others R/T paranoid thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others

4 ~ The priority nursing diagnosis for a client diagnosed with avoidant personality disorder should be social isolation R/T inability to relate to others. These clients avoid close or romantic relationships, interpersonal attachments & intimate sexual relationships.

The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that: 1. Fluid and food will be withheld the morning of the examination. 2. A tranquilizer will be given before the examination. 3. An enema will be given before the examination. 4. No special preparation is required for the examination.

4. A KUB radiographic examination ordinarily requires no preparation. It is usually done while the client lies supine and does not involve the use of radiopaque substances.

A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? 1. "I should take my antacid before I take my other medications." 2. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." 3. "My antacid will be most effective if I take it whenever I experience stomach pains." 4. "It is best for me to take my antacid 1 to 3 hours after meals."

4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect? 1. Decreased urine alkaline phosphatase level. 2. Increased urine calcium excretion. 3. Increased serum calcium level. 4. Decreased serum uric acid level.

4. By inhibiting uric acid synthesis, allopurinol (Zyloprim) decreases its excretion. The drug's effectiveness is assessed by evaluating for a decreased serum uric acid concentration. Allopurinol does not alter the level of alkaline phosphatase, nor does it affect urine calcium excretion or the serum calcium level.

A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected.

A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. to expect an immediate improvement in urinary force. d. that an intraprostatic urethral stent will be placed.

Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient a. pelvic floor muscle training. b. the use of belladonna and opium suppositories. c. how to perform intermittent self-catheterization. d. to restrict oral fluid intake.

The health care provider prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH symptom score of 12 on the AUA Symptom Index. When teaching the patient about the drug, the nurse informs him that a. his interest in sexual activity may decrease while he is taking the medication. b. he should change position from lying to standing slowly to avoid dizziness. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

When planning teaching for a patient who has had a unilateral orchiectomy and chemotherapy for testicular cancer, the nurse will include information about the need for a. regular follow-up appointments to detect other types of malignancies. b. aspiration of sperm from the remaining testis if infertility occurs. c. testosterone supplements to help maintain erectile function. d. application of ice to the scrotum to minimize pain and swelling.

Which structure of the brain contains the appetite regulation center? A. Hypothalamus. B. Medulla. C. Amygdala. D. Thalamus.

The home care nurse is making an initial follow-up visit to a client discharged post-perineal prostatectomy. Which behavior reported by the client post-suture removal should be a cause for concern? A) Use of enemas to address constipation B) Fluid intake of 2000-3000 mL per day C) Perineal irrigations with sterile normal saline after bowel movements D) Daily sitz baths

A Rationale: Due to the proximity of the incision to the anus, there is a high risk of infection. The client should not use enemas or take the temperature rectally. Sitz baths can be used to promote healing. A fluid intake of 2-3 L per day is recommended to prevent urinary tract infection. Perineal irrigations with sterile normal saline should be done after each bowel movement to help prevent infection.

A client who has been diagnosed with antisocial personality disorder (ASPD) is encouraged to participate in group therapy sessions. Which benefit should this client receive from this type of therapy? A) Strengthens empathic skills B) Provides a healthcare provider view C) Gains strength against negativity D) Solves the issue of impulsivity

A Rationale: Group therapy can be helpful in strengthening empathic skills for individuals with ASPD in that it allows for feedback about the perceptions of the other group members. Another example of group therapy is the Systems Training for Emotional Predictability and Problem Solving (STEPPS), consisting of 20 two-hour sessions led by a social worker. ASPD is not used to provide a healthcare view, resolve impulsivity, or strengthen against negativity.

A client with benign prostatic hyperplasia (BPH) asks the nurse if there are medications that can be used to prevent the need for surgery. Which response by the nurse is accurate? A) "Yes, there are medications that can help control BPH symptoms and reduce the need for surgery." B) "There are medications, but most of them have serious adverse effects." C) "There are some medications available, but ultimately they just delay the need for surgery for a short time." D) "There are two classes of medications available for BPH, but they only address lower urinary tract symptoms and do not shrink the prostate."

A Rationale: Medications such as alpha-blockers and 5-alpha reductase inhibitors have significantly reduced the need for surgery to control symptoms of BPH. The medications do have several side effects, none of which would likely be considered terrible; in particular, finasteride has no serious adverse effects. The statement that they only delay the need for surgery for a short bit is not a valid statement. Finasteride and dutasteride both cause the enlarged prostate to shrink, thus the statement that they only address lower urinary tract symptoms is not valid. OK

The nurse is caring for a client recently diagnosed with personality disorder (PD). Which pharmacologic therapy should the nurse anticipate for this client? A) Selective serotonin reuptake inhibitors (SSRIs) B) Antihypertensives C) Anticholinergics D) Beta blockers

A Rationale: SSRIs are a pharmacologic treatment for PD. Beta blockers, anticholinergic medications, and antihypertensives are not typically used in the pharmacologic treatment of PD.

The nurse is preparing a plan of care for a client with a personality disorder (PD). For which reason should the nurse spend time completing an assessment of this client? A) Behavior identification B) Work identification C) Family identification D) Drug identification

A Rationale: A goal of the nursing assessment is to identify behaviors that are associated with the PD. Family identification, drug identification, and work identification are all parts of the nursing assessment, but these are not the ultimate goal of the assessment of a client with a personality disorder.

A client receiving an alpha-adrenergic blocker, doxazosin, for treatment of the symptoms of benign prostatic hyperplasia (BPH) calls the nurse complaining of severe dizziness. How should the nurse respond to this information? A) Inform the client that these are common adverse effects and review precautions to take while on this drug. B) Inform the client that he needs to immediately quit taking the drug and see the healthcare provider. C) Tell the client that it is likely that he will need to switch to a different drug to treat the BPH symptoms. D) Ask the client to continue taking the drug, but make an appointment with the provider for follow-up.

A Rationale: Alpha-adrenergic blockers such as doxazosin can cause orthostatic hypotension, dizziness, and headaches. Thus, the client should be reminded that these are common adverse effects and that there are certain precautions such as making position changes slowly, taking and recording blood pressures daily, and checking with the healthcare provider before taking any medications for coughs, colds, or allergies. The client does not need to make an appointment with the healthcare provider for follow-up, quit taking the drug, or switch to a different medication unless the adverse effects become intolerable at which time the benefits and risks would need to be weighed.

The nurse is caring for a client diagnosed with a ureteral stone. Which assessment finding should the nurse anticipate? A) Renal colic B) Colicky pain C) Fever D) Microscopic hematuria

A Rationale: The nurse caring for the client diagnosed with a ureteral stone can anticipate renal colic. Renal colic is an acute, severe flank pain on the affected side. Fever, colicky pain, and microscopic hematuria are not clinical manifestations of a ureteral stone.

The nurse is preparing to interview a client with a personality disorder (PD). Which information should the nurse include in the health history portion of the nursing assessment for this client? A) History of drug or alcohol use B) Assessment for symptoms of cutting C) Focused system assessment D) Vital sign assessment

A Rationale: The nurse would include an assessment of the client's history of drug or alcohol use in the health history portion of the nursing assessment for a client diagnosed with a PD. A vital sign assessment, a focused system assessment, and assessing for symptoms of cutting would occur during the physical examination portion of the nursing assessment for a client who is diagnosed with a personality disorder.

A client with benign prostatic hyperplasia is noted to have a smaller prostate in his physical examination. He states he is planning on having surgery that will minimize the risk of postoperative retrograde ejaculation, but he cannot remember what it is called. Which procedure should the nurse suspect? A) Transurethral incision of the prostate B) Transurethral needle ablation C) Laser surgery D) Prostatic urethral lift

A Rationale: Transurethral incision of the prostate has a lower risk of postoperative retrograde ejaculation than a transurethral resection of the prostate and other prostatectomy procedures.

Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications? a. Milk, apples, tomatoes, and corn. b. Eggs, spinach, dried peas, and gravy. c. Salmon, chicken, caviar, and asparagus. d. Grapes, corn, cereals, and liver.

A Because a high-purine diet contributes to the formation of uric acid, a low-purine diet is advocated. An alkaline-ash diet is also advocated because uric acid crystals are more likely to develop in acid urine. Foods that may be eaten as desired in a low-purine diet include milk, all fruits, tomatoes, cereals, and corn. Foods allowed on an alkaline-ash diet include milk, fruits (except cranberries, plums, and prunes), and vegetables (especially legumes and green vegetables). Gravy, chicken, and liver are high in purine.

A nurse is caring for a client with renal calculi. Which drug does the nurse expect the physician to order? a. Opioids analgesics b. Nonsteroidal anti-inflammatory drugs c. Muscle relaxants d. Salicylates

A Opioid analgesics are usually needed to relieve the severe pain of renal calculi. NSAIDs and Salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain. Muscle relaxants are typically used to treat skeletal muscle spasms.

A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of a. acute pain related to irritation by the stone. b. deficient fluid volume related to inadequate intake. c. risk for infection related to urinary system damage. d. risk for nausea related to pain and renal colic.

A Rationale: Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain.

A patient with a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock-wave lithotripsy. Which information is most important for the nurse to collect after lithotripsy? a. Urine output b. Pain level c. Appearance of the site d. Patient temperature

A Rationale: Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to monitor the urine output. The patient may have pain as the stones pass and bruising at the site, but these are not unexpected. Extracorporeal shock wave lithotripsy (ESWL) is not associated with a risk for infection.

A client has a history of urolithiasis related to hyperuricemia. To prevent the formation of future stones, the nurse instructs the client to avoid certain foods, including: a. liver b. carrots c. skim milk d. white rice

A Rationale: Because the client has a high level of uric acid in the blood and a history of kidney stones from crystallized uric acid in the renal pelvis, the nurse instructs the client to avoid foods that contain high amounts of purines, because these foods contain a high concentration of uric acid. This includes limiting or avoiding organ meats, such as liver, brain, heart, and kidney. Other foods to avoid include sweetbreads, herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, coffee, tea, chocolate, and carbonated beverages.

A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which intervention is important? a. Strain all urine b. Limit fluid intake c. Enforce strict bed rest. d. Encourage a high-calcium diet

A Rationale: Urine should be strained for calculi and sent to the laboratory for analysis. Fluid intake of 3 to 4 qt. 3 to 4 L/day is encouraged to flush the urinary tract and prevent further calculi formation. Ambulation is encouraged to help pass the calculi through gravity. A low-calcium formation of calcium calculi.

During the nurse's assessment of a client who has been diagnosed with bulimia nervosa, the nurse evaluates certain assessment findings that accompany binge eating. Which are the most applicable? Select all that apply A. guilt B. dental caries C. self-induced vomiting D. weight loss E. normal weight F. introverted behavior

A B C E

Which of the following features is not true regarding disasters? Select all that apply. a. Spiritual distress is not a common issue following a disaster. b. Disasters can be natural or man-made. c. Children are particularly vulnerable when it comes to coping after a disaster. d. Children understand that the world will return to normal after a disaster.e. Disasters overwhelm local resources.f. Disasters may consist of infinite disruptions.

A D F

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Explore patient needs for health teaching. d. Assess for signs of impulsive eating.

A ~ For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority. The question calls for an intervention rather than an assessment.

Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer the patients requests and questions to the case manager. b. Explore the patients feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

A ~ Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. I am fat and ugly. b. What I think about myself is my business. c. I am grossly underweight, but that's what I want. d. I am a few pounds overweight, but I can live with it.

A ~ Patients diagnosed with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually disclose perceptions about self to others. The patient with anorexia will persist in trying to lose more weight.

What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? a. Respect the patients need for periods of social isolation. b. Prevent the patient from violating the nurses rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.

A ~ Patients diagnosed with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients diagnosed with schizotypal personality disorder rarely engage in behaviors that violate the nurses rights or exploit the nurse.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid

A ~ Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame.

Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa? a. I would be happy if I could lose 20 more pounds. b. My parents don't pay much attention to me. c. I'm thin for my height. d. I have nice eyes.

A ~ Patients with eating disorders have distorted body images and cognitive distortions. They see themselves as overweight even when their weight is subnormal. I'm thin for my height is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as I have nice eyes. Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9 C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36 C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature, 36.5 C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7 C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

A ~ Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

Physical assessment of a patient diagnosed with bulimia nervosa often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

A ~ Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

A ~ Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient diagnosed with borderline personality disorder.

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

A ~ SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? a. Cachexia b. Leukocytosis c. Hyperthermia d. Hypertension

A ~ The BMI value indicates extreme malnutrition. Cachexia is a hallmark of this problem. The patient would be expected to have leukopenia rather than leukocytosis. Hypothermia and hypotension are likely assessment findings.

A patient tells a nurse, I sometimes get into trouble because I make quick decisions and act on them. A therapeutic response would be: a. Lets consider the advantages of being able to stop and think before acting. b. It sounds as though youve developed some insight into your situation. c. Ill bet you have some interesting stories to share about overreacting. d. Its good that youre showing readiness for behavioral change.

A ~ The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

An outpatient diagnosed with anorexia nervosa has begun re-feeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

A ~ Weight gain of more than 2 to 5 pounds weekly may overwhelm the hearts capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

The nurse is reviewing a questionnaire completed by an adolescent client. Which predisposing factor may increase the client's risk for an eating disorder? (Select all that apply.) A) The client reports a history of childhood abuse. B) The client's mother has a history of bulimia nervosa. C)The client lists alprazolam (Xanax) on the home medication list. D) The client lists "checkout clerk in a grocery store" as the occupation. E) The client reports good family support and a healthy friendship network.

A, B, C Rationale: Familial risk factors for an eating disorder include a history of physical or sexual abuse or a genetic predisposition to an eating disorder. Anxiety requiring a prescription for alprazolam (Xanax) may be a psychological factor in the development of an eating disorder. Working in a grocery store, good family support, and a healthy friendship network are not risk factors.

Which information should the nurse include in the discharge instructions for a client who has undergone prostate surgery? (Select all that apply.) A) Activity B) Bleeding C) Bowel movements D) Sexual intercourse E) Clothing restrictions

A, B, C, D Rationale: The nurse should include information about activity—the healing period lasts 4-8 weeks. The client should be informed when to report bleeding to the healthcare provider. Teaching the client how to keep bowel movements regular and soft is important in keeping pressure off the prostate area. The client should be informed to abstain from sexual intercourse for 6 weeks after surgery. There is no specific clothing restriction for the client who has undergone prostate surgery.

The nurse is completing a physical assessment of a young adult who is being evaluated for anorexia. Which component should the nurse include in the nursing assessment? (Select all that apply.) A) Attitude toward food B) Condition of the teeth C) Body mass index (BMI) D) Current medication list E) Cognitive function findings

A, B, C, D Rationale: BMI is an important means of determining whether the client's weight is normal for the client's height. Exploring attitudes toward food gives insight regarding a healthy or unhealthy relationship with food and potential problems. A current medication list aids determination of whether weight loss or gain is a side effect and whether the client is using laxatives, diuretics, or diet aids. The condition of the client's teeth can reveal a history of vomiting. Cognitive function tests are not usually indicated in clients with eating disorders. Next Question

The nurse and a client with an eating disorder have set up a behavioral contract to guide the client toward healthier eating patterns. Which goal should be incorporated in the contract? (Select all that apply.) A) The client will not engage in purging behaviors. B) The client will maintain adequate calorie intake. C) The client will attend and participate in therapy. D) The client will limit exercise to 30 minutes per day. E) The client will stop compulsive thinking about weight.

A, B, C, D Rationale: As part of an inpatient program for eating disorders, a behavioral contract may involve refraining from purging behaviors, maintaining adequate caloric intake, avoiding excessive exercise, and participating in therapy as part of the treatment program. Clients with eating disorders may not be able to control or stop their compulsive thoughts, so including thought stopping as a goal in the behavioral contract is not realistic.

The nurse is conducting a health history for a client with manifestations of urinary calculi. Which data should the nurse collect? (Select all that apply.) A) Immobility B) Dehydration C) Excess dietary oxalate D) Dietary potassium deficiency E) Familial history of urinary calculi

A, B, C, E Rationale: Contributing factors to calculus formation include dehydration, immobility, excess dietary oxalate, and a familial history of urinary calculi. A dietary potassium deficiency does not contribute to the formation of calculus.

The nurse is preparing an in-service presentation about personality disorder (PD). Which risk factor for developing a PD should the nurse include? (Select all that apply.) A) Genetics B) Family life C) Childhood abuse D) Minimal physical activity E) Low socioeconomic status

A, B, C, E Rationale: Notable risk factors for PD include genetics, such as having relatives diagnosed with a PD or another mental illness; family life, such as an unstable home life or parental loss via death or divorce; childhood abuse, such as verbal, physical, and sexual abuse or neglect; and low socioeconomic status. Minimal physical activity is not a risk factor for developing a personality disorder.

Which elements of a health history for a client with benign prostatic hyperplasia (BPH) should be documented? (Select all that apply.) A) Pain B) Hematuria C) Risk factors D) Sexual orientation E) Urinary elimination patterns

A, B, C, E Rationale: The health history should include risk factors, urinary elimination patterns and manifestations, hematuria, and pain. Sexual orientation is not a relevant part of the health history for BPH.

The nurse is providing a seminar on antidepressant medications for clinic clients. Which information should be shared with the clients? (Select all that apply.) A) Side effects B) Adverse reactions C) Dosage and intervals D) When to stop the medication

A, B, C, E Rationale: The nurse should provide medication teaching regarding dosage and intervals, anticipated side effects, potential adverse reactions, and when to contact the healthcare provider for follow-up care. Medication should only be stopped at the advice of the healthcare provider.

The nurse is working with an adult who has been dealing with an eating disorder for the past year. The client asks the nurse about mindfulness as an approach. Which evidence concerning mindfulness should the nurse include in the response to the client? (Select all that apply.) A) Decreases binge eating B) Decreases food cravings C) Limits the likelihood of relapse D) Decreases body image concerns E) Promotes a more complete recovery

A, B, D Rationale: Research concerning the use of mindfulness indicates that it decreases binge-eating behaviors, food cravings, and body image concerns. The use of fluoxetine is known to reduce the likelihood of relapse and cognitive-behavioral therapy promotes a more complete recovery because it is a more holistic approach. OK

The healthcare provider has diagnosed a binge-eating disorder in a client. Which common complication of this disorder requires further testing? (Select all that apply.) A) Obesity B) Osteoporosis C) Heart disease D) Type 2 diabetes E) Gallbladder disease

A, C, D, E Rationale: Clients found to have binge-eating disorder should undergo a full physical examination to screen for complications of the illness, including obesity, heart disease, type 2 diabetes, and gallbladder disease. Osteoporosis is a complication of anorexia nervosa, not binge-eating disorder.

Which instruction should the nurse include to promote healing for a client being discharged post-prostate surgery? (Select all that apply.) A) Avoid strenuous activity and heavy lifting. B) Drink fruit juices and take stool softeners as ordered. C) Use NSAIDs for pain relief every 4-6 hours as needed. D) Avoid sexual activity for at least 6 weeks after surgery. E) Restrict driving time to less than half an hour at a time.

A, B, D Rationale: Upon discharge, the client should be instructed to avoid strenuous activity and heavy lifting, drink fruit juices, and take stool softeners as ordered, and to avoid sexual activity for at least 6 weeks after surgery. The client should be told not to drive for at least 2 weeks, thus indicating that it is okay to drive for short time frames is not appropriate. Additionally, NSAIDs should not be used for at least 2 weeks after surgery or as instructed by the healthcare provider.

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (SATA) a. Obsessive-compulsive b. Antisocial c. Dependent d. Schizotypal e. Narcissistic

A, B, D ~ Some personality disorders have evidence of genetic links; therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive-compulsive personality disorder.

The nurse is preparing a plan of care for a client whose anorexia nervosa is complicated by dehydration and a cardiac arrhythmia. Which outcome should the nurse consider positive for this client? (Select all that apply.) A) The client remained free of injury. B) The client increased nutritional intake by 20%. C) The client had a 24-hour fluid intake of 600 mL. D) The client attended therapy sessions as scheduled. E) The client stated that she liked how she looked in the new dress.

A, B, D, E Rationale: Positive outcomes for clients with an eating disorder include remaining free of injury, increasing nutritional intake, viewing themselves positively, and attending therapy on a consistent schedule. A fluid intake of 600 mL/day is insufficient

A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect( s) of this drug? Select all that apply. a. Nausea. b. Rash. c. Constipation. d. Flushed skin. e. Bone marrow depression.

A, B, E Common adverse effects of allopurinol (Zyloprim) include gastrointestinal distress, such as anorexia, nausea, vomiting, and diarrhea. A rash is another potential adverse effect. A potentially life-threatening adverse effect is bone marrow depression. Constipation and flushed skin are not associated with this drug.

The nurse is teaching a community-based group about reproductive health. Which information should the nurse include when discussing benign prostatic hyperplasia (BPH)? (Select all that apply.) A) BPH is the most common benign tumor in men. B) BPH is considered a precursor to prostate cancer. C) Almost all men will develop BPH if they live long enough. D) Caucasian American men develop symptoms of BPH later than all other races. E) Antioxidant and anti-inflammatory supplements can reduce the risk of BPH.

A, C Rationale: BPH is the most common benign tumor in men and almost all men will develop BPH if they live long enough. Therefore, the nurse would include these statements in the teaching session. BPH is not considered a precursor to prostate cancer. There is no evidence to support the use of antioxidant or anti-inflammatory supplements to reduce the risk of BPH. Caucasian American men do not develop symptoms of BPH later than all other races. Asian American men develop symptoms later than Caucasian American men.

A client with narcissistic personality disorder (NPD) confronts the charge nurse, demanding that only one specific nurse be allowed in the room. Which intervention should the nurse implement for this client? (Select all that apply.) A) Providing a structured inpatient milieu B) Telling the client that he cannot decide the staffing C) Allowing the client to express his feelings in an appropriate tone D) Explaining how the nurses work as a team with the client's treatment plan E) Allowing the client to choose the nurse he prefers to work with on a consistent basis

A, C, D Rationale: For a narcissistic client, the charge nurse should provide a consistent, structured, inpatient milieu to reduce staff splitting, encourage expression of feelings in appropriate ways (such as through acceptable verbal and nonverbal communication, rather than acting out), and send clear and consistent verbal and nonverbal messages to reduce confusion and misinterpretation of the treatment plan requirements. The nurse should follow the treatment plan and not allow the client to manipulate the environment. The client may become angry and violent. It is important to set limits and to be consistent as part of the treatment plan. Telling the client that he cannot choose the staffing could provoke the client and is not therapeutic.

Which is a type of psychotherapy that is used in the treatment of personality disorders? (Select all that apply.) A) Group therapy B) Physical therapy C) Schema-focused therapy D) Cognitive-behavioral therapy E) Dialectical behavioral therapy

A, C, D, E Rationale: There are several types of psychotherapy used in the treatment of PD, including cognitive-behavioral therapy, dialectical behavioral therapy, group therapy, and schema-focused therapy. Physical therapy is not a treatment for PD

Which diagnostic tests should the nurse expect to be prescribed for a client with symptoms of benign prostatic hyperplasia (BPH)? (Select all that apply.) A) Urinalysis B) Urine specific gravity test C) Digital rectal examination D) Prostate-specific antigen (PSA) level E) Ultrasound or postvoid catheterization

A, C, D, E Rationale: Urinalysis is done to identify the presence of white and red blood cells or bacteria in the urine. An ultrasound or postvoid catheterization is performed to determine residual urine volume. A PSA test screens for prostate cancer, and a digital rectal exam assesses the external surface of the prostate. A urine specific gravity test is not a part of the diagnostic screening for BPH

A client who has just undergone transurethral resection of the prostate (TURP) has developed TURP syndrome. Which finding during the nursing assessment support this diagnosis? (Select all that apply.) A) Confusion B) Hypotension C) Hypertension D) Hyponatremia E) Decreased hematocrit

A, C, D, E ationale: TURP syndrome occurs when the client absorbs the irrigation fluids during and after surgery. Clinical manifestations are hyponatremia, decreased hematocrit, hypertension, bradycardia, nausea, and confusion. If not treated promptly, TURP syndrome may result in dysrhythmias and/or seizures. Hypotension is not a manifestation of this syndrome.

The nurse meets the family of a teen who has been struggling with an eating disorder. The family expresses a preference to try complementary approaches initially to address the teen's behaviors. Which complementary therapies should the nurse recommend? (Select all that apply.) A) Yoga B) Herbs C) Massage D) Meditation E) Acupuncture

A, C, D, E Rationale: Yoga, massage, acupuncture, and meditation are all potential complementary therapies for clients with eating disorders. Because of their laxative and weight loss effects and the potential for abuse, herbs are not typically used in the treatment of eating disorders.

A client has been prescribed a 5-alpha reductase inhibitor, dutasteride (Avodart), for benign prostatic hyperplasia (BPH). Which potential adverse effect should the nurse include in the teaching for this medication? (Select all that apply.) A) Impotence B) Gynecomastia C) Decreased libido D) Renal insufficiency E) Decreased volume of ejaculate

A, C, E Rationale: Side effects of 5-alpha reductase inhibitors such as dutasteride (Avodart) and finasteride (Proscar) may include impotence, decreased libido, and decreased volume of ejaculate. Gynecomastia and renal insufficiency are not side effects for these medications.

The nurse is providing care to a client with a personality disorder (PD). Which behavior should the nurse identify that characterize the client as having antagonism? (Select all that apply.) A) Lying to parents B) Avoiding intimacy C) Feelings of grandiosity D) Exhibiting risk-taking behaviors E) Being manipulative with friends

A, C, E Rationale: The behaviors that support the characterization of antagonism include being manipulative, lying or being deceitful, and feelings of grandiosity. Avoiding intimacy supports detachment. Exhibiting risk-taking behaviors supports disinhibition.

Which risk factors should the nurse assess when performing a health history on a client for benign prostatic hyperplasia (BPH) screening? (Select all that apply.) A) Age B) Vasectomy C) Racial background D) Sexual promiscuity E) The presence of testes

A, C, E Rationale: The risk of developing BPH increases with age, generally after the age of 40. Men who had their testes removed before puberty are not at risk for BPH. Race may be a factor in BPH: African American and Hispanic males tend to develop BPH earlier than Caucasian American males, while Asian American males develop symptoms later. Having had a vasectomy and sexual promiscuity are not risk factors for BPH.

Which clinical manifestations should the nurse expect to observe when assessing a client with benign prostatic hyperplasia (BPH)? (Select all that apply.) A) Hesitancy B) Frequency C) Incontinence D) Incomplete emptying E) Weak or intermittent urinary stream

A, D, E Rationale: Symptoms of voiding BPH include hesitancy, incomplete emptying, weak or intermittent urinary stream, dribbling at the end of urination, and straining during urination. Frequency and incontinence are clinical manifestations of storage BPH, not benign BPH. OK

The nurse is caring for a client with renal calculi. Which treatment is considered supportive? (Select all that apply.) A) Increasing fluid intake B) Increasing dietary fat intake C) Maintaining the client on bedrest D) Avoiding excess calcium-containing foods E) Administering ordered medications to help prevent the formation of future stones

A, D, E Rationale: Thiazide diuretics, allopurinol, and antibiotics may help prevent the formation of future calculi. Increasing fluid intake will prevent future stones from occurring and also prevent side effects of the medications used to treat the renal calculi. Adequate fluid intake will also assist in urine formation to help pass the stones. Excess dietary intake of calcium, oxalate, or proteins can contribute to the formation of urinary calculi. Dietary fat does not usually contribute to, or prevent formation of, urinary calculi. It is important for the client to avoid immobility because it contributes to the formation of urinary calculi.

The nurse is admitting a client with suspected urinary calculi. Which collaborative activity should the nurse anticipate as part of diagnosing urinary calculi and/or the possible complications associated with this diagnosis? (Select all that apply.) A) Urinalysis B) Chest x-ray C) Renal ultrasound D) Intravenous pyelography (IVP) E) Computed tomography (CT) scan of the kidney

A,C,D,E Rationale: Urinalysis is used to assess for hematuria, WBCs, and crystal fragments. A chest x-ray would not be routinely ordered. A renal ultrasound can detect stones and hydronephrosis. A CT scan of the kidney can show calculi and obstruction. IVP can visualize the kidneys, ureters, and bladder, and it will demonstrate clear evidence of calculi.

During an admission interview, a client with anorexia nervosa complains of feeling cold all the time and asks the nurse why. Which of the following is the most appropriate response by the nurse? A. "There is a loss of subcutaneous fat." B. "You probably aren't dressing warmly enough." C. "Let me take your temperature." D. "You might be getting a cold."

A. Clients who have a history of anorexia frequently complain of feeling cold all the time that is unrelated to weather and clothing. Hypothermia is the result of dehydration or a loss of subcutaneous tissue.

During a prenatal assessment, the clinic nurse suspects that her client has been abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"

A. "Are you being threatened or hurt by your partner?"

A client with obsessive-compulsive personality disorder takes the nurse aside and mentions "I've observed you interacting with Mr. D. You are not approaching him properly. You should be more forceful with him." The best response for the nurse would be A. "I will be continuing to follow the care plan for Mr. D." B. "I see you are trying to control Mr. D's therapy as well as your own." C. "Your eye for perfection extends even to my nursing interventions." D. "Mr. D's care is really of no concern to you or to other clients."

A. "I will be continuing to follow the care plan for Mr. D." Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder.

Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? A. "Power and control are central to the dynamic of domestic violence." B. "Poor communication and social isolation are central to the dynamic of domestic violence." C. "Erratic relationships and vulnerability are central to the dynamic of domestic violence." D. "Emotional injury and learned helplessness are central to the dynamic of domestic violence."

A. "Power and control are central to the dynamic of domestic violence."

The post-cholecystectomy client asks the nurse when the t-tube will be removed. Which response by the nurse would be appropriate? A. "When your stool returns to a normal brown color, the tube can be removed." B. "The tube will be removed the same time as your staples." C. When the tube stops draining, it will be removed." D. "The tube is usually removed the day after surgery."

A. "When your stool returns to a normal brown color, the tube can be removed." When T-tube drainage subsides and stills return to a normal brown color, the tube can be clamped 1 to 2 hours before and after meals in preparation for tube removal.

A nurse is planning care for a group of clients on a mental health unit. The nurse notes that most of the assigned clients require interventions commonly used to treat anxiety disorders. Such antianxiety interventions would be appropriate for which clients? Select all that apply. A. A client with panic disorder B. Generalized anxiety disorder C. A client with multiple personality disorder D. A client with posttraumatic stress disorder (PTSD) E. A client with obsessive-compulsive disorder (OCD)

A. A client with panic disorder B. Generalized anxiety disorder D. A client with posttraumatic stress disorder (PTSD) E. A client with obsessive-compulsive disorder (OCD) Rationale: Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, generalized anxiety disorder, PTSD, and OCD.

A client has been diagnosed with dependent personality disorder. Which behavior descriptions can the nurse expect to assess? A. Anxious, fearful B. Odd, eccentric C. Dramatic, emotional, erratic D. Disoriented, disorganized

A. Anxious, fearful Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. These individuals have difficulty making independent decisions and are constantly seeking reassurance. They have deeply held convictions of personal incompetence, with the fear that they cannot survive on their own. They frequently seek treatment for anxiety or mood disorders related to a loss.

The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? A. Elevated serum indirect bilirubin B. Decreased serum protein C. Elevated urine bilirubin D. Decreased urine pH

A. Elevated serum indirect bilirubin Hemolitic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirunbin produced exceeds of red blood cells, and the ability of the liver to coajugate it, so there is an incease in indirect bilirubin.

Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply. A. Enuresis B. Red and swollen labia and rectum C. Vaginal tears D. Injuries in different stages of healing E. Cigarette burns F. Lice infestation

A. Enuresis B. Red and swollen labia and rectum C. Vaginal tears

A client is being evaluated for possible duodenal ulcer. The nurse monitors the client for which manifestation that would support this diagnosis? A. Epigastric pain relieved by food B. History of chronic aspirin use C. Distended abdomen D. Positive fluid wave

A. Epigastric pain relieved by food The pain ofa gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from duoenal ulcer. The pancreatic juices that are high in bicarbonate are released with food intake and relieve duodenal ulcer pain when the client eats.

The interventions common to treatment plans for survivors include which of the following? Select all that apply. A. Establish trust and rapport. B. Identify areas of control. C. Remove the client from the home. D. Support the client in the decisions he/she makes. E. Encourage the client to pursue legal action

A. Establish trust and rapport. B. Identify areas of control. D. Support the client in the decisions he/she makes.

A group of nursing students at Elmira College is currently learning about family violence. Which of the following is true about the topic mentioned? A. Family violence affects every socioeconomic level. B. Family violence is caused by drugs and alcohol abuse. C. Family violence predominantly occurs in lower socioeconomic levels. D. Family violence rarely occurs during pregnancy

A. Family violence affects every socioeconomic level.Rationale: Family violence occurs in all socioeconomic levels, races, religions, and cultural groups. Although violence is associated with substance abuse, it is not the singular cause. The statement that the family violence predominantly occurs in lower socioeconomic levels is false. Abuse often occurs during pregnancy; about 23% of all pregnant women seeking prenatal care are victims of abuse.

Which laboratory test would the nurse expect to be ordered for a child with dehydration caused by vomiting and diarrhea? SATA A. Serum Sodium B. Urine specific gravity C. Serum ammonia D. Serum amylase E. Blood Urea Nitrogen (BUN)

A. Serum Sodium B. Urine specific gravity E. Blood Urea Nitrogen (BUN) Serum sodium would be expected to increase in a client with dehydration because of hemoconcentration. Measuring urine specific gravity provides information regarding hydration. The BUN rises with dehydration and is therefore a general indicator of hydration status, although it also reflects kidney function.

A nurse assists a client with a diagnosis of obsessive-compulsive disorder (OCD) in his preparations for bedtime. One hour later the client calls the nurse and says that he is feeling anxious; he asks the nurse to sit and talk for a while. Which is the appropriate initial nursing action? A. Sit and talk with the client. B. Ask the unlicensed assistive personnel to sit with the client. C. Administer the prescribed as-needed antianxiety medication. D. Tell the client that it is time for sleep and that you will talk with him tomorrow.

A. Sit and talk with the client. Rationale: The appropriate initial nursing action is to sit and talk with the client if he is expressing anxiety. An unlicensed assistive personnel may not be able to alleviate the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. Option 4 is an inappropriate action and places the client's feelings on hold.

Which statement is descriptive of clients with personality disorders? A. They are resistant to behavioral change. B. They have an ability to tolerate frustration and pain. C. They usually seek help to change maladaptive behaviors. D. They have little difficulty forming satisfying and intimate relationships.

A. They are resistant to behavioral change. Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly.

A client with histrionic personality disorder winks at an attractive nurse and states, "You and I should be able to turn those resident physicians into jelly if you'd wear your skirts about two inches shorter." The nurse's reply should be based on the understanding that the client's use of seductive behavior is A. a response to stress. B. based on a need to dominate. C. seated in primitive rage. D. callous disregard for others.

A. a response to stress. The histrionic person is impulsive and melodramatic and may act flirtatious or provocative to get the spotlight in an attempt to reduce stress

A 16-year-old has stolen money from his invalid grandmother, uses drugs and alcohol, and frequently beats up acquaintances who disagree with him. Arrested for an assault in which he beat a classmate and caused brain damage, he stated in court "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of A. antisocial personality disorder. B. borderline personality disorder. C. schizotypal personality disorder. D. narcissistic personality disorder.

A. antisocial personality disorder. Clients with antisocial personality act out feelings without consideration for the rights of others. They feel no remorse for their antisocial acts.

A danger of working with a client who idealizes the nurse is A. becoming overinvolved and being protective and indulgent. B. becoming indecisive about planned interventions. C. developing a prejudicial, blaming orientation. D. stringent enforcement of boundaries and limits.

A. becoming overinvolved and being protective and indulgent. Finding an approach for helping clients with personality disorders who have overwhelming needs can be overwhelming for caregivers. For example, a borderline female client may briefly idealize her male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an exaggeration, and they have a neutral response. But after days of constant dramatic praise, some members of the team may start to feel inadequate and jealous of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect. Open communication in staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse working with these clients to maintain objectivity.

Characteristics the nurse will assess in the client with antisocial personality disorder are A. deceitfulness, impulsiveness, and lack of empathy. B. perfectionism, preoccupation with detail, and verbosity. C. avoidance of interpersonal contact and preoccupation with being criticized. D. need for others to assume responsibility for decision-making and seeks nurture.

A. deceitfulness, impulsiveness, and lack of empathy. Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others.

A nurse is assigned to work with a client with borderline personality disorder. The nurse will need to consider strategies for dealing with the client's A. mood shifts, impulsivity, and splitting. B. grief, anger, and social isolation. C. altered sensory perceptions and suspicion. D. perfectionism and preoccupation with detail.

A. mood shifts, impulsivity, and splitting. Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned. But they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

ANS: A, B The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

ANS: B Based on Maslow's hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

ANS: B The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

ANS: C Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this client's symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this client's fainting to the loss of alkaline stool due to laxative abuse which would lead to a relative metabolic acidotic condition.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Sibutramine (Meridia) D. Pemoline (Cylert)

ANS: C The nurse should teach the client that sibutramine (Meridia) is an anorexiant medication prescribed for morbidly obese clients. The mechanism of action in the control of appetite appears to occur by inhibiting the neutotransmitters serotonin and norepinephrine. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

ANS: C The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, measurable, and also include a time frame.

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60 mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the rationale for scheduling group therapy at this time? A. To shift the clients' focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

ANS: D This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family member's development of anorexia nervosa.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. "I do not use any laxatives or diuretics to lose weight." B. "I am losing lots of hair. It's coming out in handfuls." C. "I know that I am thin, but I refuse to be fat!" D. "I don't know why people are worried. I need to lose this weight."

ANS: D When the client states, "I don't know why people are worried. I need to lose this weight," the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

A nurse is reviewing d/c instructions with a client who had spontaneous passage of a calcium phosphate kidney stone. Which of the following should be included in the teaching? (select all) a. limit intake of food high in animal protein b. reduce sodium intake c. strain urine for 48 hours d. report burning with urination to the provider e. increase fluid intake to 3 L/day

All but C if the stone has passed, straining urine is no longer indicated.

When providing care for a client with glomerular disorders, the nurse teaches the client which of the following? "Healing takes a long time, so you will learn self-management." "You will be free of infection in the future." "You will face activity restrictions for the rest of your life." "You will be cured when you leave the hospital."

Answer: "Healing takes a long time, so you will learn self-management." Rationale: The client with glomerular disorders faces a healing process that may last years. Since hospitalization for that long a time is not necessary or reasonable, the nurse will teach the client how to manage the process at home. The client is not cured when discharged from the hospital. Some clients may never recover; however, activity restrictions will be based on individual tolerance and are not universally required. No client is ever free of infection.

The nurse evaluates teaching of a client with glomerulonephritis as effective when the client: Demonstrates the care for the vascular shunt or peritoneal catheter. States the need to remain on bed rest until the urine is clear yellow. Limits fluid intake to 1500 mL per day. Chooses soy or animal proteins for allowed grams of protein in the diet.

Answer: Chooses soy or animal proteins for allowed grams of protein in the diet. Rationale: Soy and/or animal protein are complete proteins that are necessary for growth and tissue healing. Complete proteins are preferred, and this client's proteins are restricted. Bed rest is necessary during the acute phase of the disease only. Dialysis is not indicated for the client with glomerulonephritis. Sodium may be restricted if the client is edematous, but fluid intake is based on the client's fluid volume status.

The nursing is planning care for the child with glomerulonephritis and teaches the family which of the following interventions of care? Encourage visitation with friends Force intake of oral fluids Provide the child with ample rest and quiet activities Promote exercise and physical activity

Answer: Provide the child with ample rest and quiet activities Rationale: The parents are taught to keep the child quiet, and activities are limited due to fatigue. Therefore, exercise and visitation by friends are limited. Fluids are often restricted until the disease begins to abate.

The nurse is caring for a child diagnosed with glomerulonephritis. Which of the following findings will the nurse expect in this client? Red-brown urine Low blood urea nitrogen (BUN) level Hypotension A urine specific gravity of 1.000

Answer: Red-brown urine Rationale: Gross hematuria is the classic sign of glomerulonephritis. The client will also experience elevated BUN levels, hypertension, and an elevated urine specific gravity.

The nurse is caring for a child diagnosed with nephrotic syndrome. Which of the following is the most appropriate nursing diagnosis for the child? Ineffective Coping Risk for Loneliness Activity Intolerance Risk for Impaired Skin Integrity

Answer: Risk for Impaired Skin Integrity Rationale: The child with nephrotic syndrome experiences edema, and is at risk for impaired skin integrity. Although the child may not tolerate activity, may not be coping well, and may be lonely, the physiological need is the priority of care.

The nurse is caring for a client diagnosed with a glomerular disorder. During teaching, the nurse tells the client that the disorder is a secondary form of the disease related to which of the following? Systemic lupus erythematosus (SLE) Azotemia Acute proliferative glomerulonephritis Goodpasture's syndrome

Answer: Systemic lupus erythematosus (SLE) Rationale: Diseases such as SLE and diabetes mellitus cause glomerular disease secondary to SLE and diabetes. Azotemia is a symptom, not a cause, of glomerular disorders. Acute proliferative glomerulonephritis and Goodpasture's syndrome are primary disease processes.

The nurse is preparing to care for a child with suspected glomerulonephritis. Which historical data collected on admission would support a diagnosis of acute glomerulonephritis? The child had nausea and vomiting virus one week ago. The child fell from a bike, landing on the left side. The child experienced a hypersensitivity reaction yesterday. The child was treated for streptococcus 2 weeks ago.

Answer: The child was treated for streptococcus 2 weeks ago. Rationale: Streptococcus infection is the cause of glomerulonephritis, which develops 1-2 weeks after the child has experienced strep throat. Nausea and vomiting, injury, and hypersensitivity reactions are not causes of glomerulonephritis.

A client is diagnosed with a calculus in the ureter. Which term should the nurse use to describe the client's condition? A) Calcium stone B) Nephrolithiasis C) Urolithiasis D) Cystine

C Rationale: Stone or calculus formation in urinary structures other than the kidney is termed urolithiasis. Cystine is a substance that contributes to stone formation. A calcium stone indicates that the stone is made of calcium. Stones or calculi formed in the kidney are termed nephrolithiasis.

When teaching a group of adolescents about anorexia nervosa, the nurse should describe this disorder as being characterized by which factor? A. near-normal weight, a self-critical body image and excessive fear of becoming obese B. chronic dieting, an altered body image and an obsession with weight of others C. calorie-counting, an unrealistic body image and concern about dieting D. emaciation, a disturbed body image, and an intense fear of becoming obese

D. emaciation, a disturbed body image, and an intense fear of becoming obese

The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? 1. Elevated serum indirect bilirubin 2. Decreased serum protein 3. Elevated urine bilirubin 4. Decreased urine pH

Answer: 1 Rationale: Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin.

A client is being evaluated for possible duodenal ulcer. The nurse assesses the client for which manifestation that would support this diagnosis? 1. Epigastric pain relieved by food 2. History of chronic aspirin use 3. Distended abdomen 4. Positive fluid wave

Answer: 1 Rationale: The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from duodenal ulcer. T

The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should the nurse make? 1. "You will be able to have some control over your bowel movements." 2. "The stoma will require that you wear a collection device all the time." 3. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch." 4. "The drainage will gradually become semisolid and formed."

Answer: 2 Rationale: A client with an ileostomy has no control over bowel movements and must always wear a collection device.

The client with a duodenal ulcer asks the nurse why an antibiotic is part of the treatment regimen. Which infor- mation should the nurse include in the response? 1. Antibiotics decrease the likelihood of a secondary infection. 2. Many duodenal ulcers are caused by the Helicobacter pylori organism. 3. Antibiotics are used in an attempt to sterilize the stomach. 4. Many people have Clostridium difficile, which can lead to ulcer formation.

Answer: 2 Rationale: Helicobacter pylori infection is a major cause of peptic ulcers so treatment includes antibiotic therapy to eradicate the microorganisms.

The client returning from a colonoscopy has been given a diagnosis of Crohn's disease. The oncoming shift nurse expects to note which manifestations in the client? Select all that apply. 1. Steatorrhea 2. Firm, rigid abdomen 3. Constipation 4. Enlarged hemorrhoids 5. Diarrhea

Answer: 1, 5 Rationale: Steatorrhea is often present in the client with Crohn's disease.

The nurse admits a client diagnosed with a renal calculus located in the left ureter. Other than pain, what is the priority nursing diagnosis for this client? a Impaired Urinary Elimination b Knowledge Deficit c Alteration in Fluid Volume: Excess d Electrolyte Imbalance: Potassium

a. impaired urinary elimination

A nurse is administering a prescribed dose of IV fluid to a young client with anorexia at the healthcare facility. When reviewing the client's medical record, which of the following would the nurse identify as a possible cause for the client's anorexia? A. Motion Sickness B. Gastrointestinal Dysfunction C. General Anesthesia D. Inner Ear Infection

In caring for a client 4 days post-cholecystectomy, the nurse notices that drainage from the T-tube is 600 mL in 24 hours. Which is the most appropriate action by the nurse? 1. Clamp the tube q 2 hours for 30 minutes 2. Place the patient in a supine position 3. Assess drainage characteristics and notify the physician 4. Encourage an increased fluid intake

Answer: 3 Rationale: The T-tube may drain up to 500 mL in the first 24 hours and decreases steadily thereafter.

Nurse Naomi observes Ashley who is hospitalized due to an eating disorder unit during mealtimes and for 1 hour after eating. An explanation for this intervention is: A. To reinforce the behavioral contact B. To prevent purging behaviors C. To develop a trusting relationship D. To maintain focus on the importance of nutrition

Answer: B. To prevent purging behaviors. Option B: Ashley may experience increased anxiety during treatment and, therefore, may resume behaviors designed to prevent weight gain, such as vomiting or excessive exercise.

A client is scheduled for a fecal fat exam. In planning client education, the nurse includes that which dietary modification is necessary before the test? 1. Eat a fat-free diet the day before the exam. 2. Eat a high-fat meal right before the exam. 3. Eat a diet containing 35 grams of fat for 36 hours before the test. 4. Eat at least 100 grams of fat for 3 days before and during the test.

Answer: 4 Rationale: It is suggested that adults consume at least 100 grams of fat per day for 3 days before the test and throughout specimen collection.

A client was admitted to the hospital with cholelithiasis the previous day. Which new assessment finding indicates to the nurse that the stone has probably obstructed the common bile duct? 1. Nausea 2. Elevated cholesterol level 3. Right upper quadrant (RUQ) pain 4. Jaundice

Answer: 4 Rationale: Nausea and RUQ pain occur in cholelithiasis, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice.

During the admission process, the parents of a newly diagnosed 17-year-old with anorexia nervosa often make this remark about the teenager with anorexia nervosa? a. "We have had many concerns about her. She does poorly in school." b. "We have never had any problems with her. She gets really good grades in school." c. "She is so outgoing and gregarious that we never suspected an issue." d. "We have spoiled her too much, it is our fault."

4. The health care provider prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH symptom score of 12 on the AUA Symptom Index. When teaching the patient about the drug, the nurse informs him that a. his interest in sexual activity may decrease while he is taking the medication. b. he should change position from lying to standing slowly to avoid dizziness. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

Answer: A Rationale: A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Orthostatic hypotension is a side effect of the α-blocking agents. Improvement in symptoms of obstruction takes 3 to 6 months. The medication does not cause hypertension. Cognitive Level: Application Text Reference: p. 1417 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected.

Answer: A Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. Cognitive Level: Application Text Reference: p. 1418 Nursing Process: Implementation NCLEX: Physiological Integrity

11. Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient a. pelvic floor muscle training. b. the use of belladonna and opium suppositories. c. how to perform intermittent self-catheterization. d. to restrict oral fluid intake.

Answer: A Rationale: Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. Cognitive Level: Application Text Reference: p. 1428 Nursing Process: Planning NCLEX: Physiological Integrity

8. A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. to expect an immediate improvement in urinary force. d. that an intraprostatic urethral stent will be placed.

Answer: A Rationale: The patient will have indwelling catheter for up to a week and will need to be instructed on catheter care to avoid problems such as infection. There is minimal bleeding with this procedure. It will take several weeks before the full benefits of the procedure take effect. Stent placement is not included in the procedure. Cognitive Level: Application Text Reference: pp. 1420-1422 Nursing Process: Planning NCLEX: Physiological Integrity

A client is experiencing severe upper abdominal pain and jaundice. Which finding on the cholescintigraphy should indicate to the nurse that the client has cholelithiasis? A. Obstruction of the cystic duct by a gallstone B. Viral infection of the gallbladder C. Accumulation of fat in the wall of the gallbladder D. Accumulation of bile in the hepatic duct

Answer: A Rationale: Cholelithiasis is almost always caused by a gallstone lodged in the cystic duct. Accumulation of bile in the hepatic duct would not lead to cholecystitis. Neither the accumulation of fat nor a viral infection leads to cholecystitis.

The nurse is teaching a client with cholelithiasis about lifestyle modification. Which statement made by the client indicates that the nurse's teaching has been successful? A. "I will walk three times a week for 20 minutes each day." B. "I will eliminate salt from my diet." C. "I can fry food as long as I use olive oil instead of vegetable oil." D. "I will use more ground beef in my meal preparation."

Answer: A Rationale: Obesity is commonly associated with the development of gallbladder disease. A balanced diet and exercise will help keep the client's weight within normal limits. There is no reason to eliminate salt from the diet. Ground beef is high in fat and should be limited. Frying adds additional fat and should be avoided.

A client is experiencing pain and nausea related to biliary colic. Which statement should the nurse make to manage this client's symptoms? (Select all that apply.) A. "Medication will help with the nausea and vomiting." B. "Intravenous fluids will ensure that you are well hydrated." C. "It's important for you to be comfortable so that you can rest." D. "Pain medication will be prescribed." E. "A bland diet helps with nausea."

Answer: A, B, C, D Rationale: Clinical therapies for treating biliary colic include administering analgesics, getting adequate rest, correcting fluid and electrolyte imbalances, and administering antiemetics.

The nurse prepares discharge teaching for a client recovering from a cholecystectomy. Which topic should the nurse include in this teaching? (Select all that apply.) A. Surgical incision care B. Manifestations of postoperative complications C. Pain control measures D. Activity level E. High-fat diet

Answer: A, B, C, D Rationale: The nurse will instruct the client on the prescribed activity level, manifestations of postoperative complications that must be reported to the healthcare provider, pain control measures, and surgical incision care. A low-fat, not high-fat, diet must be followed by this client after discharge.

While providing teaching to a young adult during an annual health exam, the nurse discusses health problems common during this stage of development. What is the most common cause of mortality during this stage? a. Suicide b. Drug Overdose c. Eating Disorders d. Motor Vehicle Crashes

Answer: D. Motor vehicle crashes Injuries are the leading cause of death for adolescents and young adults. Motor vehicle crashes are the most common cause of mortality, often associated with the use of alcohol or other drugs.

A client is recovering from a laparoscopic cholecystectomy. Which nursing action should the nurse use to reduce this client's risk of infection? (Select all that apply.) A. Monitor vital signs, including temperature, every 4 hours. B. Administer antibiotics as prescribed. C. Coach to take deep breaths every 1dash2 hours while awake. D. Assess the abdomen every 4 hours. E. Place in Fowler position.

Answer: A, B, C, D Rationale: To reduce the risk of infection, the nurse will monitor vital signs, including temperature, every 4 hours, because changes may be the first sign of infection. Assessment of the abdomen can reveal signs of a surgical wound infection. Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. Antibiotics are used to control infection. Fowler position may enhance the client's comfort but will have no effect on postsurgical infection.

A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing action should the nurse use to address this client's nutritional status? (Select all that apply.) A. Counseling regarding low-fat menu choices B. Administering antiemetics as prescribed C. Assessing height and weight D. Advising to consume a low-protein diet E. Reviewing serum electrolytes

Answer: A, B, C, E Rationale: Assessing height and weight, reviewing serum electrolytes, counseling on low-fat menu choices, and administering antiemetics as prescribed are all nursing actions that address the client's nutritional status. A high-protein, not low-protein, diet is used to treat cholecystitis.

A client with cholelithiasis is not a surgical candidate at this time. Which pharmacologic treatment should the nurse expect to be prescribed for this client? (Select all that apply.) A. Ursodiol B. Chenodiol C. Antibiotics D. Antipyretics E. Cholestyramine

Answer: A, B, C, E Rationale: Pharmacologic treatment for gallstones is used for clients who refuse surgery or for whom surgery is contraindicated. Medications used in the treatment of gallstones include ursodiol, chenodiol, antibiotics, cholestyramine, and opioid analgesics. Antipyretics are a pharmacologic treatment for fever, not cholelithiasis itself.

The nurse evaluates a client's understanding of discharge teaching following a laparoscopic cholecystectomy. Which client statement indicates teaching has been effective? (Select all that apply.) A. "I will take my pain medicine on an empty stomach to get the maximum benefit." B. "I will be sure to get up and walk every hour." C. "I can have some hot chocolate with my breakfast." D. "I will increase the protein in my diet by drinking whole milk."

Answer: A, B, D Rationale: Clients from a laparoscopic cholecystectomy are often treated in day surgery, but discharge instructions should be similar to those for other clients who have had abdominal surgery. Therefore, they should be informed to be sure to increase their activity level when they return home. Clients should take pain medications with food to diminish irritation to the stomach lining. The client should follow a diet low in fat and high in fat-soluble vitamins. Therefore, including hot chocolate and whole milk would not be appropriate food choices.

A client with right upper quadrant abdominal pain asks why so many tests are being scheduled. Which is the reason that the nurse should give to this client? (Select all that apply.) A. To identify possible complications B. To determine if gallstones are present C. To prevent recurrence D. To determine the location of gallstones E. To diagnose the disorder

Answer: A, B, D, E Rationale: Diagnostic tests are used to identify the presence and location of gallstones, identify possible complications of the gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.

A middle-aged female client who is obese has been experiencing right upper quadrant abdominal pain for the past several hours. For which risk factors of gallstone development should the nurse assess this client during the health history? (Select all that apply.) A. Excess cholesterol B. Inflammation of the gallbladder C. Biliary colic D. Biliary stasis E. Abnormal bile composition

Answer: A, B, D, E Rationale: The formation of gallstones occurs when several factors are present, including abnormal bile composition, biliary stasis, inflammation of the gallbladder, and excess cholesterol. Excess cholesterol in bile is associated with obesity, a high-calorie and high-cholesterol diet, and drugs that lower serum cholesterol levels. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. Biliary colic does not lead to the formation of gallstones.

The nurse is providing dietary teaching to a client with a history of gallstones. Which diet should the nurse recommend? (Select all that apply.) A. High protein B. Low sodium C. Low fat D. High vitamin C E. High carbohydrate

Answer: A, C Rationale: A low-carbohydrate, low-fat, high-protein diet reduces symptoms of cholecystitis. While fasting and very low-calorie diets are contraindicated, a moderate reduction in caloric intake and increased activity levels promote weight loss.

The nurse is preparing health promotion teaching for a client with gallbladder disease. Which topic should the nurse include in the teaching session? (Select all that apply.) A. Role of a high-cholesterol diet on gallstone formation B. Role of hypolipidemia on gallstone formation C. Importance of a low-cholesterol diet D. Dangers of rapid weight loss E. Importance of a high-fiber diet

Answer: A, C, D, E Rationale: Clients should be taught about the role of obesity, hyperlipidemia, and a high-cholesterol diet on gallstone formation; the importance of a high-fiber, low-fat, and low-cholesterol diet to reduce the incidence of gallbladder disorders; and the dangers of rapid weight loss. Hypolipidemia does not promote gallstone formation.

A client scheduled for a cholecystectomy asks what caused the gallstones to develop. Which risk factor should the nurse list when responding to this client? (Select all that apply.) A. American Indian ethnicity B. Male sex C. Family history of gallstones D. Obesity E. Hyperlipidemia

Answer: A, C, D, E Rationale: The risk factors for developing gallbladder disorders include age, family history of gallstones, American Indian ethnicity, obesity, hyperlipidemia, female sex, pregnancy, diabetes mellitus, cirrhosis, ileal disease, and sickle cell disease. Men have a lower risk of developing gallbladder disorders.

A pregnant client of American Indian heritage experiences mild gastric distress and nausea after eating large meals and constant sharp abdominal pain. Which additional information should the nurse collect during the interview? (Select all that apply.) A. History of chronic diseases B. Expected due date C. Length of time the symptoms last and when they occur D. Smoking history E. Other symptoms F. Current diet

Answer: A, C, E, F Rationale: The nurse should note current manifestations, including right upper quadrant (RUQ) abdominal pain, and its character and relationship to meals, duration, and radiation; nausea and vomiting; other symptoms; duration of symptoms; risk factors or previous history of symptoms; chronic diseases such as diabetes, cirrhosis, or IBD; current diet; and use of oral contraceptives or possibility of pregnancy.

24. A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "The prostate gland normally changes slightly in size from day to day, and this may be making your symptoms worse." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate?" d. "I will talk to the doctor about ordering a prostate specific antigen test."

Answer: B Rationale: Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer and is not indicated in this patient, who has already been diagnosed with BPH. Cognitive Level: Application Text Reference: p. 1421 Nursing Process: Assessment NCLEX: Physiological Integrity

12. Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will increase fiber and fluids in my diet to prevent constipation." b. "I should call the doctor if I have any incontinence at home." c. "I will avoid heavy lifting or driving until I get approval from my health care provider." d. "I should continue to schedule yearly appointments for prostate exams."

Answer: B Rationale: Incontinence is common for several weeks after a TURP. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. Cognitive Level: Application Text Reference: p. 1422 Nursing Process: Evaluation NCLEX: Physiological Integrity

27. A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order to a. schedule the patient for inpatient hemodialysis. b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

Answer: B Rationale: The patient data indicate that the patient may have hydronephrosis and acute renal failure caused by the BPH; the initial therapy will be to insert a catheter. Hemodialysis may be needed if the elevation in BUN and creatinine persists, but it will not be ordered initially. Fluid administration and furosemide administration will increase the bladder distension. Cognitive Level: Application Text Reference: p. 1415 Nursing Process: Planning NCLEX: Physiological Integrity

7. The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

Answer: B Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation. Cognitive Level: Comprehension Text Reference: pp. 1420-1421 Nursing Process: Implementation NCLEX: Physiological Integrity

While admitting a teenage client who has a diagnosis of anorexia, the client informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? a. Record it in the client's record b. Validate the weight loss with the client c. Inform the client that this cannot be correct d. Ignore this information completely and continue collecting data

Answer: B When data given appears to be distorted, the client Question refers to anorexia nervosa.

A client with acute cholecystitis is experiencing jaundice. Which should the nurse consider as the reason for the jaundice? A. Viral infection of the gallbladder B. Obstruction of the cystic duct by a gallstone C. Accumulation of bile in the hepatic duct D. Accumulation of fat in the wall of the gallbladder

Answer: B Rationale: When acute cholecystitis is accompanied by jaundice, partial common duct obstruction is likely, which is usually due to stones or inflammation.

A client asks what causes gallstones to form. Which factor should the nurse explain as being present when these stones are formed? (Select all that apply.) A. Rapid weight gain B. Abnormal bile composition C. Excess cholesterol D. Inflammation of the gallbladder E. Biliary stasis

Answer: B, C, D, E Rationale: Gallstones are formed due to abnormal bile composition, an inflammation of the gallbladder, biliary stasis, and excess cholesterol. Rapid weight loss, not weight gain, is a factor that contributes to the formation of gallstones.

Nurse Donald is planning a psychoeducational discussion for a group of adolescent clients with anorexia nervosa. Which of the following topics would Nurse Donald select to enhance understanding about central issues in this disorder? A. Peer pressure and substance abuse B. Self-esteem and self-control C. Anger management D. Parental expectations

Answer: B. Self-esteem and self-control Option B: Self-esteem and self-control are central issues for clients with eating disorders. Such clients feel a loss of self-control over their life and experience diminished self-esteem and severe doubts about their self-worth.

3. A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk. b. prevention is not possible because prostatic enlargement occurs with normal aging. c. decreasing butter and margarine and increasing fruits in the diet may help. d. taking a daily vitamin E supplement has reduced prostate size in some men.

Answer: C Rationale: A diet high in saturated fats, found in foods like butter, is associated with an increased risk for BPH. Individuals who eat more fruits and vegetables may be at lower risk. Riding a bicycle does increase prostate-specific antigen (PSA) levels, but this is not associated with development of BPH. Dietary changes and increased exercise do appear to help prevent BPH. Vitamin E supplements do not decrease prostate size. Cognitive Level: Comprehension Text Reference: p. 1415 Nursing Process: Implementation NCLEX: Physiological Integrity

5. A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an elevated PSA level. The nurse will anticipate that the patient will need teaching about a. uroflometry studies. b. cystourethroscopy. c. transrectal ultrasonography (TRUS). d. magnetic resonance imaging (MRI).

Answer: C Rationale: In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to help differentiate BPH from prostatic cancer. Uroflowmetry studies will help determine the extent of urine blockage and treatment, but a differential diagnosis will be obtained first. Cystourethroscopy may be used after TRUS if the diagnosis is still uncertain. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. Cognitive Level: Application Text Reference: p. 1416 Nursing Process: Planning NCLEX: Physiological Integrity

1. To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

Answer: C Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH. Cognitive Level: Application Text Reference: pp. 1415-1416 Nursing Process: Assessment NCLEX: Physiological Integrity

Which is a risk factor for gallbladder disease? A. Male gender B. Hypocalcemia C. Rapid weight loss D. Hypolipidemia

Answer: C Rationale: Rapid weight loss, hyperlipidemia (not hypolipidemia), and female (not male) gender are risk factors for gallbladder disease. Hypocalcemia is not a risk factor.

When teaching a group of adolescents about anorexia nervosa, the nurse should describe this disorder as being characterized by which factor? a. near-normal weight, a self-critical body image and excessive fear of becoming obese b. chronic dieting, an altered body image and an obsession with the weight of others c. calorie-counting, an unrealistic body image and concern about dieting d. emaciation, a disturbed body image, and an intense fear of becoming obese

Answer: D An intense fear of becoming obese, emaciation, and a disturbed body image all are considered to be characteristic of anorexia nervosa. Near-normal weight is not associated with anorexia. The weight of others is not a primary factor. Concern about dieting is not strong enough language to describe the control of food intake in the individual with anorexia nervosa.

9. The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse's response is based on the knowledge that a. elevated levels of PSA are indicative of metastatic cancer of the prostate. b. PSA testing is the "gold standard" for making a diagnosis of prostate cancer. c. baseline PSA levels are necessary to determine whether treatment is effective. d. PSA levels are usually elevated in patients with cancer of the prostate.

Answer: D Rationale: PSA levels are usually elevated above the normal in patients with prostate cancer. PSA testing does not determine whether metastasis has occurred. A biopsy of the prostate is needed for a definitive diagnosis of prostate cancer. Success of treatment is determined by a fall in PSA to an undetectable level; the patient's baseline PSA is not needed to determine the success of treatment. Cognitive Level: Application Text Reference: p. 1423 Nursing Process: Implementation NCLEX: Physiological Integrity

A client who is morbidly obese is diagnosed with acute cholelithiasis. Which nonpharmacologic therapy should the nurse expect to be prescribed for this client? A. Parenteral nutrition B. Fat-soluble vitamins C. Bile salts D. Withholding all oral intakes and inserting a nasogastric tube

Answer: D Rationale: During an acute attack of cholecystitis, food should be eliminated and a nasogastric tube inserted to relieve nausea and vomiting. Parenteral nutrition is not indicated at this time. Once the client is eating again, dietary fat intake may be limited, especially if the client is obese. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered but this would be considered a pharmacologic therapy.

The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing gallstones? A. Young adult Asian American women B. Middle-aged Caucasian American men C. African American clients D. Women over the age of 40

Answer: D Rationale: Genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. Female sex, being over the age of 40, American Indians, and Mexican Americans are most at risk for gallstones. Family history is also associated with increased risk.

The nurse is teaching a client with cholelithiasis about a new prescription for ursodiol. Which client statement indicates to the nurse that the teaching was successful? A. "If I take this for a long time it might damage my liver, so I will need checkups of my liver function." B. "There is a good chance I will experience diarrhea, so I might need my dosage reduced." C. "This medicine should take away the orange color from my skin." D. "I might have some slight diarrhea or constipation, but that is a normal side effect of the medicine."

Answer: D Rationale: Ursodiol is a bile acid. It is used to dissolve gallstones in clients who cannot have surgery to remove gallstones. Ursodiol is also used to prevent the formation of gallstones in clients who are overweight or who are losing weight very quickly. It works by decreasing the production of cholesterol and by dissolving the cholesterol in bile so that it cannot form stones. Ursodiol is generally well tolerated but can cause diarrhea or constipation.

A client with acute nephrotic syndrome asks the nurse how the disease will be treated. The nurse tells the client that treatment will likely include: (Select all that apply.) Plasmapheresis. Dialysis. ACE inhibitors. Digoxin for renal failure. Glucocorticoids.

Answers: Glucocorticoids. ACE inhibitors. Rationale: Glucocorticoids such as prednisone are used to induce remission in nephrotic syndrome. ACE inhibitors are use to reduce protein loss in the urine. Digoxin is a cardiac medication. Plasmapheresis is used to treat Goodpasture's syndrome, and dialysis is used for renal failure.

The nurse is completing a physical assessment of a young adult who is being evaluated for anorexia. Which component should the nurse include in the nursing assessment? (Select all that apply.) Attitude toward food Condition of the teeth Body mass index (BMI) Current medication list Cognitive function findings

Attitude toward food Condition of the teeth Body mass index (BMI) Current medication list BMI is an important means of determining whether the client's weight is normal for the client's height. Exploring attitudes toward food gives insight regarding a healthy or unhealthy relationship with food and potential problems. A current medication list aids determination of whether weight loss or gain is a side effect and whether the client is using laxatives, diuretics, or diet aids. The condition of the client's teeth can reveal a history of vomiting. Cognitive function tests are not usually indicated in clients with eating disorders.

A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of a. hydrocele. b. varicocele. c. epididymitis. d. paraphimosis.

A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order tO a. schedule the patient for inpatient hemodialysis. b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "The prostate gland normally changes slightly in size from day to day, and this may be making your symptoms worse." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate?" d. "I will talk to the doctor about ordering a prostate specific antigen test."

Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will increase fiber and fluids in my diet to prevent constipation." b. "I should call the doctor if I have any incontinence at home." c. "I will avoid heavy lifting or driving until I get approval from my health care provider." d. "I should continue to schedule yearly appointments for prostate exams."

In teaching a male patient to perform testicular self-examination, the nurse includes the information that a. the only structure normally felt in the scrotal sac is the testis. b. the examination should be done when the scrotum is warm. c. an appointment with the health care provider is needed if one testis is larger than the other. d. an examination should be performed whenever the patient showers or bathes.

Leuprolide (Lupron) and bicalutamide (Casodex) are prescribed for a patient with cancer of the prostate. In teaching the patient about these drugs, the nurse informs the patient that side effects may include a. low blood pressure. b. decreased sexual drive. c. urinary incontinence. d. frequent infections.

The doctor is considering whether to prescribe testosterone replacement therapy for a 62-year-old man who is concerned about a gradual decrease in sexual performance. Which information obtained by the nurse is most important to communicate to the doctor? a. The patient states that he has noticed a decrease in energy level for a few years. b. The patient has had a gradual decrease in the force of his urinary stream. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient's symptoms have increased steadily over the last few years.

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? A. "I can expect yellow-green drainage from the incision for a few days." B. "I can remove the bandages on my incisions tomorrow and take a shower." C. "I should plan to limit my activities and not return to work for 4 to 6 weeks." D. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

B Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

The nurse is assessing a client who is obese and reports eating to the point of discomfort at least twice a week for the past year. The client denies the use of laxatives, self-induced vomiting, ipecac syrup, or enemas and reports feeling unable to control the behavior. The client feels embarrassed and has stopped going out with friends. Which eating disorder should the nurse suspect? A) Anorexia nervosa B) Binge-eating disorder C) Bulimia nervosa D) Purging

B Rationale: The information shared by the client describes the classic manifestations of binge-eating disorder, not bulimia nervosa or anorexia nervosa. Purging is a symptom, not an eating disorder in and of itself

Which symptom indicates to the nurse that the client may still have an infection related to renal calculi? A) Oral temperature of 99.1°F B) Cloudy urine C) Nausea and vomiting D) Right flank pain

B Rationale: A client with renal calculi is at risk of developing a urinary tract infection. Cloudy urine would be an indicator of infection. Nausea and vomiting often occur with renal calculi but do not indicate infection. An oral temperature of 99.1°F does not indicate infection, but it is an indicator of possible dehydration. Right flank pain is a common clinical manifestation of renal calculi and does not indicate infection.

The nurse is assessing a client who is receiving morphine sulfate IV for pain from urinary calculi. Which assessment finding is a priority to communicate to the healthcare provider? A) The client is hyperventilating. B) The client has respirations of 8 breaths per min and oxygen saturation of 90%. C) The client has frequent loose stools. D) The client has nausea.

B Rationale: A decreased respiratory rate with low blood oxygen levels are side effects of IV morphine. Nausea is a side effect of morphine but is not a priority. Hyperventilation and frequent loose stools do not normally occur as side effects of morphine.

A client is tentatively diagnosed with schizotypal personality disorder (Cluster A). Which assessment finding should the nurse identify that supports this client's diagnosis? A) Panic B) Paranoia C) Irritability D) Impulsivity

B Rationale: Common cognitive traits of the schizotypal personality disorder include: extreme suspicion of others, paranoid fears of persecution, and odd or distorted thoughts. Panic, irritability, and impulsivity are not characteristics of this disorder.

The nurse is conducting a seminar on benign prostatic hyperplasia (BPH) for older men. Which statement is accurate in describing the pathophysiologic change of the aging prostate that contributes to the development of BPH? A.) "Testosterone levels decrease, thereby decreasing inhibition of prostate growth." B) "The prostate becomes more sensitive to available dihydrotestosterone." C.) Estrogen levels decrease, contributing to prostatic hyperplasia." D) "The prostate increases the production of dihydrotestosterone."

B Rationale: Dihydrotestosterone (DHT) mediates prostatic growth. Estrogen appears to sensitize the aging prostate to available DHT, ultimately contributing to prostatic hyperplasia. Increasing estrogen levels, not decreasing levels, contribute to prostatic hyperplasia. The prostate becomes more sensitive to DHT; DHT production is not increased. The statement concerning testosterone levels is not a valid statement.

An 18-year-old client who is diagnosed with antisocial personality disorder (PD) has been arrested and committed to a 72-hour hold. Which nursing assessment data support this client's diagnosis? A) Suicidal ideations B) Feelings of agitation C) Poorly developed interpersonal skills D) Feelings of emptiness

B Rationale: Feelings of agitation are an expected assessment finding for clients with antisocial PD. Other manifestations are impulsiveness, lack of remorse, failure to empathize, aggression, and controlling behaviors. Feelings of emptiness, poorly developed interpersonal skills, and suicidal ideations are manifestations expected for a client with borderline PD.

The nurse is discussing schema-focused therapy (SFT) with a group of new nurses. Which response indicates an understanding of the type of client for whom this therapy would be most beneficial? A) "A client who secludes herself from others." B) "A client who thinks he is a horrible person." C) "A client who is experiencing auditory hallucinations." D) "A client who self-harms frequently."

B Rationale: Schema-focused therapy (SFT) combines aspects of cognitive-behavioral therapy (CBT) with other forms of psychotherapy to change a client's self-perception. This is often applied to personality disorders, where the client typically has a poor self-image. SFT aims to help clients view themselves differently, so they can create new and more effective ways of interacting with their environment and others.

After an intravenous pyelogram (IVP), the nurse should anticipate incorporating which of the following measures into the client's plan of care? a. Maintaining bed rest. b. Encouraging adequate fluid intake. c. Assessing for hematuria. d. Administering a laxative.

B After an IVP, the nurse should encourage fluids to decrease the risk of renal complications caused by the contrast agent. There is no need to place the client on bed rest or administer a laxative. An IVP would not cause hematuria.

Allopurinol (Zyloprim), 200 mg/ day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which of the following adverse effects of this medication? a. Retinopathy. b. Maculopapular rash. c. Nasal congestion. d. Dizziness.

B Allopurinol (Zyloprim) is used to treat renal calculi composed of uric acid. Adverse effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients should be instructed to report rashes and unusual bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not adverse effects of allopurinol.

Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic? a. Applying moist heat to the flank area. b. Administering meperidine (Demerol). c. Encouraging high fluid intake. d. Maintaining complete bed rest.

B During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics to control the pain. Application of heat, encouraging high fluid intake, and limitation of activity are important interventions, but they will not relieve the renal colic pain.

The client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which of the following would the nurse include on the client's postoperative care? a. Sterile irrigation of the Penrose drain b. Frequent dressing changes around the Penrose drain c. Weighing the dressings d. Maintaining the client's position on the affected side

B Frequent dressing changes around the Penrose drain is required to protect the skin against breakdown from urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine through the drain.

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time? a. Report hematuria to the physician. b. Strain the urine carefully. c. Administer meperidine (Demerol) every 3 hours. d. Apply warm compresses to the flank area.

B Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics should be administered when the client needs them, not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened.

The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes. b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits.

B Rationale: Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

The client who has a history of gout also is diagnosed with urolithiasis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: a. Milk b. Liver c. Apples d. Carrots

B Rationale: The client with uric acid stones should avoid foods containing high amounts of purines. This includes limiting or avoiding organ meats such as liver, brain, heart, kidney, and sweetbreads. Other foods to avoid include herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages.

The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to a. report the pain level when the stone passed. b. collect the stone and bring it to the clinic. c. record the time that the stone passed. d. save a urine specimen to check for blood.

B Rationale: The patient should save the stone for analysis of the stone composition, which will help in determining treatment. Reporting the pain level and recording the time the stone passed are not essential. Hematuria is common with urinary calculi, so it is not necessary to test the urine for blood.

The client with urolithiasis has a history of chronic urinary tract infections. The nurse plans teaching the client to avoid which of the following? a. Long-term use of antibiotics. b. Wearing synthetic underwear and pantyhose. c. High--phosphate foods, such as dairy products. d. Foods that make the urine more acidic, such as cranberries.

B Rationale: Urolithiasis (struvite stones) can result from chronic infections. They form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Teaching should focus on prevention of infections and ingesting foods to make the urine more acidic. The client should wear cotton (not synthetic) underclothing to prevent the accumulation of moisture and to prevent irritation of the perineal area, which can lead to infection.

In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for signs of: a. Nephritis. b. Referred pain. c. Urine retention. d. Additional stone formation.

B The pain associated with renal colic due to calculi is commonly referred to the groin and bladder in female clients and to the testicles in male clients. Nausea, vomiting, abdominal cramping, and diarrhea may also be present. Nephritis or urine retention is an unlikely cause of the referred pain. The type of pain described in this situation is unlikely to be caused by additional stone formation.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patients feelings about cutting.

B ~ A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The incorrect options provide positive reinforcement of the behavior.

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs of the patient are met. d. Because of increased risk for physical problems with re-feeding, obtaining patient permission is required.

B ~ A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that the patient's needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? A. The patient's urine is bright yellow. B. The patient's stools are tan colored. C. The patient has increased pain after eating. D. The patient complains of chronic heartburn.

B. Rationale: Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. The nurses comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

B ~ In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate oral intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

B ~ One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. She wears layered, loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating disorder b. Anorexia nervosa c. Bulimia nervosa d. Pica

B ~ Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. Pica refers to eating nonfood items.

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

B ~ Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients diagnosed with eating disorders. The incorrect options are rare in a patient with anorexia nervosa. Inflexibility, controlled emotions, and pessimism are more the norm.

Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.

B ~ Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress.

A nurse in the emergency department tells an adult, Your mother had a severe stroke. The adult tearfully says, Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious. Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

B ~ The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of re-feeding. c. Communicate empathy for the patients feelings. d. Help the patient balance energy expenditure and caloric intake.

B ~ The nursing intervention of observing for adverse effects of re-feeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perceptionauditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping

B ~ Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority.

A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (SATA) a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

B, D ~ Individuals diagnosed with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals diagnosed with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals diagnosed with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

The nurse is assessing a 19 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A. Increased sodium retention B. Decreased potassium C. Decreased albumin D. Increased serum glucose

B. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration.

Teaching in relation to home management after a laparoscopic cholecystectomy should include A. Keeping the bandages on the puncture sites for 48 hours. B. Reporting any bile-colored drainage or pus from any incision. C. Using over-the-counter antiemetics if nausea and vomiting occur. D. Emptying and measuring the contents of the bile bag from the T tube every day

B. Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should a nurse make? A. "You will be able to have some control over your bowel movements." B. "The Stoma will require that you wear a collection device all the time." C. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch." D. "The drainage will gradually become semisolid and formed."

B. "The Stoma will require that you wear a collection device all the time." A client with an ileostomy has no control over bowel movements and must always wear a collection device. The drainage tends to be liquid but becomes pastelike with intake of specific foods.

A nurse is performing an assessment on a client admitted to the mental health unit. The nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? A. Fears B. Actions C. Illusions D. Thoughts

B. Actions Rationale: A compulsion is a repetitive act. The client with a phobia is likely to experience repetitive fears. Illusions are characteristic of schizophrenia. An obsession is a repetitive thought.

The nurse is conducting dietary education with a client who has dumping syndrome. The nurse encourages the client to avoid which foods that the client usually enjoys? SATA A. Eggs B. Cheese C. Fruit D. Pork E. Cookies

B. Cheese E. Cookies Dumping syndrome, in which fastric contents rapidly enter the bowel, can occur following gastrectomy. Dietary fats and proteins are increased, and carbohydrates, especially simple carbohydrates such as fruits and desserts, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms associated with dumping syndrome.

The client with a duodenal ulcer asks the nurse why an antibiotic is part of the treatment regime. Which information should the nurse include in the response? A. Antibiotics decrease the likelihood of infection B. Many duodenal ulcers are caused by the Helicobacter pylori organism C. Antibiotis are used in an attempt to sterilize the stomach D. Many people have Clostridium difficile, which can lead to ulcer formation

B. Many duodenal ulcers are caused by the Helicobacter pylori organism Helicobacter pylori infection is a major cause of peptic ulcers so treatment includes antibiotic therapy to eradicate the microorganisms.

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? a. Hypoglycemia b. Metabolic Alkalosis c. Metabolic Acidosis d. Hyperkalemia

B. Metabolic Alkalosis if hypokalemia was on here it would be the best answer

The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother asks why the child's vomitus appears different from that of her other children when they have the flu. The nurse would explain that the eyes is of an infant with pyloric stenosis does not contain bile for which reason? A. The GI system is still immature in newborns and infants B. The obstruction is above bile duct C. The emesis is from passive regurgitation D. The bile duct is obstructed

B. The obstruction is above bile duct In pyloric stenosis, ile is unable to enter the stomach from the duodenum because the pylorus muscle is hypertropkied, which causes the obstruction.

A community health nurse working with a group of 5th grade girls is planning a primary prevention to help the girls avoid developing eating disorders during their teen years. The nurse should focus on which factor? A. working with the school nurse to closely monitor the girls' weight during middle school B. helping the girls accept and appreciate their bodies and feel good about themselves C. limiting the girls access to media images of very thin models and celebrities D. telling the girls' parents to monitor their daughter's weight and media access

B. helping the girls accept and appreciate their bodies and feel good about themselves

Research has indicated that antisocial personality may be characterized by: A. social isolation. B. lack of remorse. C. learning difficulties. D. difficulty with reality testing.

B. lack of remorse. The antisocial personality exhibits a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior towards others.

A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to A. set firm limits on behavior. B. respect need for social isolation. C. encourage expression of feelings. D. involve in milieu and group activities.

B. respect need for social isolation. Schizoid personality disorder has the primary feature of emotional detachment. The person does not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization

Playing one staff member against another is an example of A. devaluation. B. splitting. C. impulsiveness. D. social ineptitude.

B. splitting. Splitting involves setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases.

During the admission process, the parents of a newly diagnosed 17 year old with anorexia nervosa often remark about the teenager. . . A. we have had many concerns about her, she does poorly in school B. we have never had any problems with her, she gets really good grades in school C. she is so outgoing and gregarious that we never suspected an issue D. we have spoiled her too much, it's our fault

B. we have never had any problems with her, she gets really good grades in school

The nurse is assessing a client who is obese and reports eating to the point of discomfort at least twice a week for the past year. The client denies the use of laxatives, self-induced vomiting, ipecac syrup, or enemas and reports feeling unable to control the behavior. The client feels embarrassed and has stopped going out with friends. Which eating disorder should the nurse suspect? Purging Anorexia nervosa Binge-eating disorder Bulimia nervosa

Binge-eating disorder The information shared by the client describes the classic manifestations of binge-eating disorder, not bulimia nervosa or anorexia nervosa. Purging is a symptom, not an eating disorder in and of itself.

A client is discussing her feelings regarding her eating disorder with the nurse. The client shares that when she looks in a mirror, she sees herself as fat even though her BMI is 18. With which thought pattern is this statement consistent? Therapeutic relationship Deception Purging Body image distortion

Body image distortion In body image distortion, a person's view of her image is different from the reality, representing a distorted thought pattern. A therapeutic relationship is one in which there is respect, consistency, trust, and patience between a client and the healthcare provider. Purging is the act of removing all food from the body. Deception is the act of not being truthful.

A 22-year-old man tells the nurse at the health clinic that he has recently become unable to achieve an erection. When assessing for possible etiologic factors, which question should the nurse ask first? a. "Have you been experiencing an unusual amount of stress?" b. "Do you have any history of an erection that lasted for 6 hours or more?" c. "Are you using any recreational drugs or drinking a lot of alcohol?" d. "Do you have any chronic diseases, such as diabetes mellitus?"

A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk. b. prevention is not possible because prostatic enlargement occurs with normal aging. c. decreasing butter and margarine and increasing fruits in the diet may help. d. taking a daily vitamin E supplement has reduced prostate size in some men.

A 64-year-old man undergoes a perineal radical prostatectomy for stage C prostatic cancer. Postoperatively, the nurse establishes the nursing diagnosis of risk for infection related to a. urinary stasis. b. urinary incontinence. c. possible fecal contamination of the surgical wound. d. placement of a suprapubic catheter into the bladder.

A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an elevated PSA level. The nurse will anticipate that the patient will need teaching about a. uroflometry studies. b. cystourethroscopy. c. transrectal ultrasonography (TRUS). d. magnetic resonance imaging (MRI).

During discharge instructions for a patient following a laparoscopic cholecystectomy, the nurse advises the patient to A. keep the incision areas clean and dry for at least a week B. report the need to take pain medication for shoulder pain C. report any bile colored or purulent drainage from the incisions D. expect some postoperative nausea and vomiting for a few days

Following laparoscopic cholecystectomy, the nurse would expect the patient to A. return to work in 2 to 3 weeks B. be hospitalized for 3 to 5 days postoperatively C. have four small abdominal incisions covered with small dressings D. have a T tube placed in the common bile duct to provide bile drainage

The nurse will teach the patient with chronic bacterial prostatitis that a. PSA elevation indicates that he has concurrent prostate cancer. b. Nonsteroidal antiinflammatory drugs (NSAIDs) usually provide adequate pain control. c. sexual intercourse and masturbation will relieve symptoms. d. antibiotics should be taken for 7 to 10 days.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. testicular torsion. b. STD infection. c. undescended testicles. d. testicular trauma.

When performing discharge teaching for a patient who has undergone a vasectomy in the health care provider's office, the nurse instructs the patient that a. he may have temporary erectile dysfunction (ED) because of postoperative swelling. b. he should not have sexual intercourse until his 6-week follow-up visit. c. he should continue the use of other methods of birth control for 6 weeks. d. he will notice a decrease in the appearance and volume of his ejaculate.

A client with a history of kidney stones formed from calcium phosphate asks the nurse, "Why are you recommending exercise to prevent another kidney stone?" Which response by the nurse is accurate? A) "Exercise promotes the retention of calcium in the bones." B) "Exercise will help you decrease your weight, which is a contributing factor to kidney stones." C) "Exercise will help move the calcium back into your bones." D) "Exercise will help excrete the calcium from your body."

C Rationale: A high blood level of calcium can result in the formation of calcium phosphate kidney stones. Exercise promotes the retention of calcium in the bones. If the client's blood level of calcium is high, weight-bearing exercise is an intervention that can help return the calcium to the bones. Calcium is not excreted from the body through exercise. Weight is not a contributing factor to kidney stones.

Which activity should the nurse instruct a client with a genetic defect of the urinary tract to perform? A) Increase exercise. B) Limit foods high in oxalate. C) Restrict dietary sodium. D) Decrease dietary purine.

C Rationale: Cystine stones are the most common type of stone formation in clients with genetic defects. Restriction of dietary sodium and increased hydration are recommended to prevent further stone formation. Increased exercise is beneficial to all clients, but not specifically to clients at risk for cysteine stones. Decreased dietary purine decreases the risk of uric acid stone formation. Limiting foods high in oxalate will help prevent the formation of calcium oxalate stones.

A client with benign prostatic hyperplasia (BPH) exhibits decreased bladder capability and bladder instability. Which should the nurse recognize as the cause of this condition? A) Development of bladder diverticula B) Increased prostate sensitivity to dihydrotestosterone C) Hypertrophic detrusor muscle D) Increased intra-abdominal pressure

C Rationale: Hypertrophy of the detrusor muscle of the bladder to compensate for increased resistance eventually results in bladder instability and decreased bladder capability. Increased intra-abdominal pressure, bladder diverticula, and increased prostate sensitivity to dihydrotestosterone are all factors in the development of BPH but are not the response to increased resistance to urinary flow that results in decreased bladder capability and bladder instability.

The nurse is counseling a teen with anorexia nervosa (AN) who is trying to manage the disorder. Which type of therapy should the nurse discuss with the client? A) Daily fluoxetine therapy B) Dialectical behavior therapy C) Family therapy D) Schema-focused therapy

C Rationale: Systemic family therapy and family-based therapy are focused on family strengths and family narratives. These are often used with adolescent anorexic clients, mobilizing the family as the primary resource in feeding and restoring health to the undernourished client. Fluoxetine is approved by the FDA for use with bulimia only, not with anorexia. Schema-focused therapy and dialectical behavior therapy are used for personality disorders, not anorexia.

An adolescent is hospitalized with anorexia nervosa. The nurse enters the client's room and finds him doing sit-ups. The nurse should: a. wait until he finishes and ask him why he feels the need to exercise. b. remind him that if he loses weight, he will lose privileges. c. ask him to stop doing the sit-ups and direct him to a quiet activity. d. leave the room and allow him to exercise in private.

C exercise is purging activity, don't want to let them engage in that activity thus why A is not correct.

A client with microscopic hematuria is diagnosed with urinary calculi. Which laboratory assessment should the nurse monitor? A) Kidney function studies B) Serum calcium, phosphorus, and uric acid levels C) Hemoglobin and hematocrit D) BUN and creatinine

C Rationale: A clinical finding of microscopic hematuria indicates that there is blood in the urine. The hemoglobin and hematocrit will be monitored as part of the treatment. BUN and creatinine are monitored with a diagnosis of acute hydronephrosis to determine the extent of kidney damage. The evaluation of kidney function will be monitored for a client with chronic hydronephrosis. Serum calcium, phosphorus, and uric acid levels are obtained to help identify factors contributing to calculus formation.

The nurse is admitting a client who is bent over and guarding the left lower side of the back. The client appears pale and has cool and clammy skin. Which is the nurse's priority intervention? A) Assist the client into a supine position. B) Initiate IV therapy. C) Assess the client's vital signs. D) Obtain a urine sample.

C Rationale: Acute severe flank pain and pale, cool, and clammy skin are clinical manifestations of a ureteral stone. The nurse will obtain the client's vital signs and then assist the client into a supine position for further physical assessment. Initiation of IV therapy and obtaining a urine sample can be done after the client's initial assessment.

The nurse is orienting a new nurse in the inpatient care unit. Which statement should the nurse include in the orientation regarding a nurse-client relationship that would ensure effective treatment of clients with eating disorders? A) These clients can be very manipulative, and their behavior must be recognized so that it can be addressed immediately and effectively. B) It is best not to trust what clients tell you about their eating habits; they hide their behaviors. C) It is hard for clients to be open about eating disorders, so nurses must be respectful and patient and develop trust. D) Very clear structure is necessary for these clients, and avoiding opportunities for the client to split staff is absolutely crucial.

C Rationale: Clients with eating disorders have generally been very secretive about their disorders, so it is a major challenge for them to become open about them. To support this openness, nurses must establish a therapeutic relationship based on trust, which requires patience, respect, and consistency. Though these clients can be secretive, telling the new nurse not to trust them would impede development of a therapeutic relationship. Most inpatient programs do have a structure, which is important for nurses to follow, but this does not best support the development of a therapeutic relationship with clients. Manipulative behaviors are characteristic of many mental health issues, but recognition of them does not best support effective treatment through the nurse-client relationship.

A client has been diagnosed with a calcium phosphate kidney stone. Which contributing factor should the nurse assess? A) Consumption of foods high in acid B) Consumption of foods high in purine C) Consumption of foods high in calcium D) Consumption of foods high in phosphate

C Rationale: Consumption of foods high in calcium can be a contributing factor to the formation of calcium phosphate kidney stones. Management includes limiting foods high in calcium and increasing foods that acidify the urine. Foods high in purine contribute to the formation of uric acid stones. Phosphates bind with calcium to decrease the blood level of calcium.

The family of a teen with anorexia nervosa is discussing treatment options with the nurse. They would like to find an inpatient program to treat their child, who has a BMI of 17 kg/m2. How should the nurse respond? A) "An inpatient stay would be a good idea if you can afford it as they have the highest success rates." B) "What would your child rather do? If the client isn't interested in an inpatient program, it probably won't be effective." C) "Initially, it is best to start with a structured day treatment program rather than an inpatient stay." D) At this point, family and group therapy would be a better option than an inpatient program."

C Rationale: Day treatment programs are considered the first-line treatment approach, so the nurse would indicate that this would be the best way to begin treatment, especially since the client has mild anorexia as indicated by the BMI. Family and group therapy will not provide the more intensive structure of a day program. An inpatient program is the next line of treatment if a day treatment program does not produce the desired outcome and the client continues to lose weight.

The nurse is caring for a client who has been diagnosed with urinary calculi. The client reports a pain level of 0 on a 0-10 scale, is drinking an adequate amount of fluids, and has been taking frequent walks in the hallway. The nurse is responsible for which intervention at this time? A) Teaching the client the importance of fluid restriction B) Requesting an order for bedrest because the client has been taking frequent walks C) Teaching the client to retrieve stones by straining all urine D) Ordering appropriate pain medication if indicated

C Rationale: The client or the nurse must retrieve stones by straining all urine. The nurse cannot order medication. Fluids need to be increased, not decreased. Ambulation assists urination; therefore, the client should not be put on bedrest.

The nurse is caring for a client being treated for a personality disorder (PD). Which finding should the nurse identify that supports this diagnosis? A) Episodes of mania B) Depressed mood C) Weak sense of self D) Fear of specific objects

C Rationale: The finding that supports the diagnosis of PD is a weak sense of self. Severe mood swings between depression and mania are common with bipolar disorder. A depressed mood is associated with the different types of depression. Fear of specific objects is a clinical manifestation of phobias.

A client is hospitalized for anorexia nervosa. The client's BMI on admission is 14.8 kg/m2. The client has been started on an antidepressant, cognitive-behavioral therapy (CBT), and a weight-restoration plan. Monitoring for which possible complication should be a priority for the nurse as the client begins eating again? A) Increased depression B) Purging C) Refeeding syndrome D) Edema

C Rationale: The nurse should monitor the client for refeeding syndrome, which is dangerous and a potentially fatal condition that can occur when clients who are severely malnourished begin eating again. The other items are not as serious of priorities as refeeding syndrome.

Which follow-up care should the nurse implement for a child previously treated for urolithiasis? A) Urine calcium level B) Urinalysis C) 24-hour urine sample D) Urine uric acid level

C Rationale: The recommended follow-up care for the child previously treated for urolithiasis is diligent screening for risk factors by collection of a 24-hour urine sample to evaluate the presence of hypercalciuria, hyperuricosuria, hypomagnesuria, hyperoxaluria, and hypocitraturia, to prevent renal insufficiency. A urinalysis is an assessment for a UTI. Urine calcium and uric acid levels are included in the 24-hour urine sample.

A client is demonstrating behaviors of being dramatic, emotional, and erratic. Based on these assessment findings, which cluster of personality disorders should the nurse document for this client? A) Cluster D B) Cluster C C) Cluster B D) Cluster A

C Rationale: There are a number of different personality disorders, each with specific characteristics. They are commonly divided into three clusters (categories), with common traits that characterize the disorders within each cluster. Cluster B characteristics include dramatic, emotional, and erratic behaviors; therefore, the nurse would document this type of personality disorder in the client's medical record. The client's assessment findings do not support the other clusters.

The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation? a. Ensuring adequate fluid intake on the day of the test. b. Preparing the client for the possibility of bladder spasms during the test. c. Checking the client's history for allergy to iodine. d. Determining when the client last had a bowel movement.

C A client scheduled for an IVP should be assessed for allergies to iodine and shellfish. Clients with such allergies may be allergic to the IVP dye and be at risk for an anaphylactic reaction. Adequate fluid intake is important after the examination. Bladder spasms are not common during an IVP. Bowel preparation is important before an IVP to allow visualization of the ureters and bladder, but checking for allergies is most important.

A nurse is instructing a client with renal calculi about recommended daily fluid consumption. The nurse would be most helpful by telling the client to drink approximately: a. 4 cups per day b. 8 cups per day c. 12 cups per day d. 16 cups per day

C A client with renal calculi should drink 3L (12 cups) of fluid per day.

The nurse is receiving in transfer from the postanesthesia care unit a client who has had a percutaneous ultrasonic lithrotripsy for calculuses in the renal pelvis. The nurse anticipates that the client's care will involve monitoring which of the following? a. Suprapubic tube b. Urethral stent c. Nephrostomy tube d. Jackson-Pratt drain

C A nephrostomy tube is put in place after a percutaneous ultrasonic lithotripsy to treat calculuses in the renal pelvis. The client may also have a foley catheter to drain urine produced by the other kidney. The nurse monitors the drainage from each of these tubes and strains the urine to detect elimination of the calculus fragments.

The client passes a urinary stone, and lab analysis of the stone indicates that it is composed of calcium oxalate. Based on this analysis, which of the following would the nurse specifically include in the dietary instructions? a. Increase intake of meat, fish, plums, and cranberries b. Avoid citrus fruits and citrus juices c. Avoid green, leafy vegetables such as spinach. d. Increase intake of dairy products.

C Oxalate is found in dark green foods such as spinach. Other foods that raise urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea.

To prevent the recurrence of renal calculi, the nurse teaches the patient to a. avoid all sources of dietary calcium. b. drink diuretic fluids such as coffee. c. drink 2000 to 3000 ml of fluid a day. d. use a filter to strain all urine.

C Rationale: A fluid intake of 2000 to 3000 ml daily is recommended help flush out minerals before stones can form. Patients are not advised to avoid all calcium-containing foods and a high calcium intake may decrease the incidence of some types of stones. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

A nurse is providing d/c instructions to a client who is postop from a TURP. Which of the following instructions should the nurse include? select all a. avoid sexual intercourse for 3 months after the surgery b. if urine appears bloody, stop activity and rest c. avoid drinking caffeinated beverages d. take a stool softener q day e. treat pain with ibuprofen

b. excessive activity may cause recurrence of bleeding c. caffeine is a bladder stimulent d. stool softener can prevent bleeding from a BM a. avoid sex for 2-6 weeks e. avoid NSAIDS d/t bleeding

A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy (ESWL). The nurse assesses to ensure that which of the following items are in place or maintained before sending the client for the procedure? a. IV line and a foley catheter b. NPO status and a foley catheter c. signed informed consent, NPO status, and an IV line d. signed informed consent and clear liquid restriction preprocedure

C Rationale: ESWL is done with conscious sedation or general anesthesia. The client must sign an informed consent form for the procedure and must be NPO for the procedure. The client needs an IV line for the procedure as well. A Foley catheter is not needed.

A nurse is evaluating discharge instructions to a client admitted for urolithiasis. Which of the following statements made by the client indicates to the nurse a need for further instructions? a. "I will report any changes in the amount or character of urine to my physician." b. "If I have any pain during urination, I will inform my physician." c. "I will drink at least 2000 mL of fluid per day." d. "I will report any blood in my urine."

C Rationale: Measures to prevent further urolithiasis include increasing fluid intake to 2500 to 3500 mL per day. The client is also instructed to report any changes in the amount or character of urine. Dysuria, frequency, urgency, and cloudy urine are symptoms of a urinary tract infection, often associated with urolithiasis. Hematuria is often associated with calculi and with procedures used to remove stones.

The client with urolithiasis has a history of chronic urinary tract infections. The nurse concludes that this client most likely has which of the following types of urinary stones? a. Calcium oxalate b. Uric acid c. Struvite d. Cystine

C Rationale: Struvite stones commonly are referred to as infection stones because they form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Calcium oxalate stones result from increased calcium intake or conditions that raise serum calcium concentrations. Uric acid stones occur in clients with gout. Cystine stones are rare and occur in clients with a genetic defect that results in decreased renal absorption of the amino acid cystine.

A client has passed a renal calculus. The nurse sends the specimen to the laboratory so it can be analyzed for which of the following factors? a. Antibodies b. Type of infection c. Composition of calculus d. Size and number of calculi

C The calculus should be analyzed for composition to determine appropriate interventions such as dietary restrictions. Calculi don't result in infections. The size and number of calculi aren't relevant, and they don't contain antibodies.

Nurse Joy is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: a. limit oral fluid intake for 1 to 2 weeks. b. report the presence of fine, sandlike particles through the nephrostomy tube. c. notify the physician about cloudy or foul-smelling urine. d. report bright pink urine within 24 hours after the procedure.

C The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal due to residual stone products. Hematuria is common after lithotripsy.

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6 ° F (38.1 ° C). Which of the following would be a priority outcome for this client? a. Prevention of urinary tract complications. b. Alleviation of nausea. c. Alleviation of pain. d. Maintenance of fluid and electrolyte balance.

C The priority nursing goal for this client is to alleviate the pain, which can be excruciating. Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the client's hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid and electrolyte imbalance.

A client with renal calculi is advised to restrict calcium in the diet. The nurse determines that the client understands the restriction when the client states to avoid which types of foods? a. chicken, beef, salmon b. green veggies, fruit, legumes c. chocolate, smoked fish, low-fat milk d. eggs, meat, poultry

C chocholate, smoked fish, milk, beans, lentils, and dried fruits are all high in calcium

A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patients wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patients behavior

C ~ A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

C ~ Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control.

A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask: a. Do you often feel fat? b. Who plans the family meals? c. What do you eat in a typical day? d. What do you think about your present weight?

C ~ Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships

C ~ Frequent team meetings are held to counteract the effects of the patients attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

C ~ Limits must be set in areas in which the patients behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters.

The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.

C ~ Maintaining consistent limits is by far the most difficult intervention because of the patients superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques.

Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: Youre a better nurse than the day shift nurse said you were; Another nurse said you dont do your job right; You think youre perfect, but Ive seen you make three mistakes. Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing.

C ~ Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments.

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

C ~ The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, Just leave it on the table. Ill take it when I finish combing my hair. What is the nurses best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, Im worried that you might not take it. I will come back later. c. Say to the patient, I must watch you take the medication. Please take it now. d. Ask the patient, Why dont you want to take your medication now?

C ~ The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patients safety, as well as to prevent splitting other staff members. Why questions are not therapeutic.

A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, Im feeling empty and want to cut myself. The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

C ~ The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for coaching during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patients ability to weigh alternatives to mutilating behavior.

The nurse is preparing a client for a transurethral needle ablation (TUNA) for benign prostatic hyperplasia (BPH). For which reason should the nurse expect that the client has selected this surgical procedure? (Select all that apply.) A) It is not expensive. B) It is easy to perform. C) It is minimally invasive. D) It does not cause impotence. E) It does not cause incontinence.

C, D, E Rationale: The TUNA is a minimally invasive surgery that uses low-level radio frequency through twin needles to burn away a region of the enlarged prostate. The urethra is protected by a shield. This procedure improves urine flow through the urethra without causing impotence or incontinence. It is not necessarily easier to perform or less expensive than other procedures.

A client with dependent personality disorder who had been living with her newly married son was admitted a week ago for treatment of depression, which began after her son suggested that she move out. Which remark by the client would the nurse evaluate as showing improvement in the client's condition? A. "My son's suggestion hurt me greatly." B. "My son is less at fault than my daughter-in-law." C. "I'm going to need help to afford to rent an apartment." D. "How will I ever live alone with no one to look after my affairs?"

C. "I'm going to need help to afford to rent an apartment." Dependent personality disorder has a primary feature of extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends. Clients have a deeply held conviction of personal incompetence, with the fear that they cannot survive on their won. Self reflection on the possibility of moving into an apartment shows improvement.

An older male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling." The health care provider should assess the patient for what factor that may put him at risk for a urinary tract infection (UTI)? A. High-purine diet B. Sedentary lifestyle C. Benign prostatic hyperplasia (BPH) D. Recent use of broad-spectrum antibiotics

C. Benign prostatic hyperplasia (BPH) BPH causes urinary stasis, which is a predisposing factor for UTIs. A sedentary lifestyle and recent antibiotic use are unlikely to contribute to UTIs, whereas a diet high in purines is associated with renal calculi.

Clinical manifestations of acute glomerulonephritis include which of the following? A. Chills and flank pain B. Oliguria and generalized edema C. Hematuria and proteinuria D. Dysuria and hypotension

C. Hematuria and proteinuria Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.

Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back

C. Hypertension, oliguria, and fatigue Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.

A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit which of the following characteristics? A. Frequent episodes of psychosis B. Constant involvement with the needs of significant others C. Inflexible and maladaptive responses to stress D. Abnormal ego functioning

C. Inflexible and maladaptive responses to stress Personality patterns persist unmodified over long periods of time. Characteristics of inflexible and maladaptive response to stress is one of these characteristics for individuals with personality disorder.

Which client with a personality disorder is most likely to be admitted to a psychiatric unit? A. Mr. A, with paranoid personality disorder who is suspicious of his neighbors B. Mr. B, with narcissistic personality disorder who is highly self-important C. Ms. C, with borderline personality disorder who is impulsive D. Mrs. D, with dependent personality disorder who clings to her husband

C. Ms. C, with borderline personality disorder who is impulsive Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times.

An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? A. Renal calculi B. Renal trauma C. Recent sore throat D. Family history of acute glomerulonephritis

C. Recent sore throat The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.

During a home visit to a family of three: a mother, a father, and their child, The mother tells the community nurse that the father (who is not present) has hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse? A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening. B. The nurse commends the mother's efforts and agrees to let her handle things. C. The nurse commends the mother's efforts and also contacts protective services. D. The nurse confronts the mother's failure to protect the child.

C. The nurse commends the mother's efforts and also contacts protective services. Rationale: WE ARE MANDATED REPORTERS OF ABUSE

The priority nursing intervention for a client with borderline personality disorder is to A. protect other clients from manipulation. B. respect the client's need for social isolation. C. assess for suicidal and self-mutilating behaviors. D. provide clear, consistent limits and boundaries.

C. assess for suicidal and self-mutilating behaviors. One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress.

What is the primary diagnostic criteria for anorexia nervosa? A. sense of lack of control over eating B. woman has amenorrhea for 2 months C. fear of being overweight when body mass index is <18.5 D. person engages in episodes of fasting or excessive exercise of >1 1/2 hours per day

C. fear of being overweight when body mass index is <18.5

Characteristic behaviors the nurse will assess in the narcissistic client are A. dramatic expression of emotion, being easily led. B. perfectionism and preoccupation with detail. C. grandiose, exploitive, and rage-filled behavior. D. angry, highly suspicious, aloof, withdrawn behavior.

C. grandiose, exploitive, and rage-filled behavior. Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem.

Clients with personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is A. spiritual distress. B. defensive coping. C. impaired social interaction. D. disturbed sensory perception.

C. impaired social interaction. For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used.

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be the most appropriate to make to this client? A. you need to stop that behavior now. B. you will need to be placed in seclusion C. you seem restless. tell me what is happening. D. you will need to be restrained if you do not change your behavior.

C. you seem restless. tell me what is happening.

A client admitted with possible kidney stones develops sudden complaints of acute crampy pain on the left side that radiates into the groin. The client is nauseated, and vomits clear fluid. On voiding, his urine is pink. The nurse should: a. Administer the prescribed narcotic analgesic. b. Notify the physician. c. Obtain a bladder scan to assess for residual urine. d. Strain all urine.

b. notify the physician

Which assessment finding should alert the nurse to a possible client diagnosis of nephritis? (Select all that apply.) Complaint of cough Complaint of weight loss Presence of infection Presence of facial edema History of diabetes

Complaint of cough Presence of infection Presence of facial edema History of diabetes Facial edema is a manifestation of nephritis due to the retention of sodium and water. A client complaint of cough may indicate Goodpasture syndrome, a rare genetic disorder that causes nephritis and may cause a cough due to antibody destruction of alveoli. Infection may cause nephritis. A client with diabetes is more prone to developing nephritis due to vascular damage to the glomerulus. Weight loss is not a manifestation of nephritis.

The nurse teaches a client diagnosed with nephritis about risk factors for the disease. Which disease should the nurse list as being likely to cause nephritis? Congestive heart failure Celiac disease Asthma Graves disease

Congestive heart failure Congestive heart failure can damage the kidneys due to hypoxia and hypoperfusion, thereby causing nephritis. None of the other diseases listed in this question causes nephritis.

A 46-year-old man has had erectile dysfunction (ED) for about 3 years when he finally seeks help for the problem. He tells the nurse that he decided to seek help because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is a. risk for anxiety related to inability to perform sexually. b. situational low self-esteem related to loss of satisfying sexual activity. c. ineffective sexuality patterns related to ED. d. ineffective role performance related to effects of ED.

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

Josephine Hites, an 80-year-old retired dress shop clerk, is reporting for her semiannual physical exam at the primary care group where you practice nursing. She demonstrates an unintentional weight loss of 10 lb in the last 6 months. When asked, she reports, "Food just doesn't taste good anymore!" What could be the cause of her reaction to food? a. Increased oxygenation to brain's appetite centers b. Too much distraction at mealtime c. Increased salivation diluting flavors d. Reduced number of taste buds

The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse's response is based on the knowledge that a. elevated levels of PSA are indicative of metastatic cancer of the prostate. b. PSA testing is the "gold standard" for making a diagnosis of prostate cancer. c. baseline PSA levels are necessary to determine whether treatment is effective. d. PSA levels are usually elevated in patients with cancer of the prostate.

The nurse is caring for two assigned clients, one with anorexia and the other with bulimia. The nurse expects that the most common coexisting mental health issue with both clients is which of the following? a.Anxiety b.Panic attacks c.Agoraphobia d.Depression

The nurse is interviewing a client admitted with anorexia and expects to find that the client manages anxiety in which of the following ways? a.Reinforces self-approval b.Needs to be perfect with decision making c.Breaks rules d.Follows rigid rules

The nurse should monitor the client with bulimia nervosa for which complication? a.Metabolic alkalosis b.Pulmonary effusion c.Excessive salivation d.Orthostatic hypotension

The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the doctor first? a. A 23-year-old man who states he had difficulty maintaining an erection last night b. A 44-year-old man who has perineal pain and a temperature of 100.4° F c. A 62-year-old man who has light pink urine after having a TURP 3 days ago d. A 66-year-old man who has a painful erection that has lasted over 9 hours

A client is discussing her feelings regarding her eating disorder with the nurse. The client shares that when she looks in a mirror, she sees herself as fat even though her BMI is 18. With which thought pattern is this statement consistent? A) Deception B) Therapeutic relationship C) Purging D) Body image distortion

D Rationale: In body image distortion, a person's view of her image is different from the reality, representing a distorted thought pattern. A therapeutic relationship is one in which there is respect, consistency, trust, and patience between a client and the healthcare provider. Purging is the act of removing all food from the body. Deception is the act of not being truthful.

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. What are your feelings about not eating the food that you prepare? b. You seem to feel much better about yourself when you eat something. c. It must be difficult to talk about private matters to someone you just met. d. Being thin does not seem to solve your problems. You are thin now but still unhappy.

D ~ The correct response is the only strategy that attempts to question the patients distorted thinking.

The nurse is providing a teaching session to care providers concerning the identification of eating disorders (EDs) in the pediatric population. Which statement would help pediatric care providers identify EDs in younger clients? A) "EDs are less likely in younger clients with a history of obesity." B) "Unwillingness to try new foods is an early indication of EDs in young clients." C) "EDs in younger clients are often associated with anxiety disorders." D) "Younger clients with EDs tend to be boys."

D Rationale: EDs in younger clients are underdiagnosed by pediatric care providers. The rate of EDs in younger clients is higher in boys than in girls; the male/female ratio is 6:1. EDs are more, not less, likely in younger clients with a history of obesity. EDs in adolescents are often associated with anxiety disorders. Unwillingness to try new foods is characteristic of a picky eater; while a child with an ED may have some picky-eating behaviors, the primary criterion is inadequate (restrictive) intake, manifested by a disinterest in food; the intake does not support the child's nutritional or energy needs.

The nurse plans care for a client being treated for an eating disorder. Which question should the nurse ask to encourage the client to re-experience positive emotions? A) "Can you describe things that trigger eating disordered behaviors for you?" B) "Do you use alcohol to help deal with the feelings and emotions you're experiencing?" C) "Do you feel that the environment you live and work in contributes to high amounts of stress for you?" D) "What kinds of things did you enjoy doing before the eating disorder took over?"

D Rationale: Encouraging clients to reconnect with activities and experiences that they previously enjoyed can help them begin to regain control over their own behaviors and re-experience positive emotions. Questions about triggers, alcohol use, and environmental stressors are also important but would not directly elicit information to support development of an intervention to promote re-experiencing of positive emotions.

Which information should the nurse provide for an older adult with gout, to prevent uric acid stones? A) "Limit dairy products." B) "Increase acidic foods." C) "Decrease sodium intake." D) "Limit meat intake."

D Rationale: Gout and increased purine intake predispose the client to uric acid stones. The client will be instructed to limit meat intake. Meat is high in purine, which contributes to the formation of uric acid stones. Increasing acidic foods is encouraged for clients with calcium phosphate or oxalate stones. Dietary sodium restriction is implemented in the plan of care for a client with a history of cysteine stones.

A client with an eating disorder has been hospitalized for medical stabilization. Which intervention should the nurse include to address energy expenditure? A) Monitoring vital signs and electrolyte levels B) Monitoring cardiovascular and respiratory response to activity C) Eliminating caffeine and other stimulants from the client's diet D) Limiting the client's activity and restricting exercise

D Rationale: In clients with eating disorders who are hospitalized for medical stabilization, it is important to limit activity and manage energy expenditure. Monitoring of vital signs, electrolyte levels, and cardiovascular/respiratory responses to exercise may also be included, but these interventions do not directly address energy expenditure. Eliminating caffeine and other stimulants from the client's diet can help decrease anxiety but does not directly address energy expenditure.

The nurse is assigned a client who was admitted to the hospital against her own will. Which action should the nurse take to establish a trusting relationship with this client? A) Encouraging her feedback B) Limiting her contact with others C) Being available to meet all of her needs D) Being consistent with client care

D Rationale: Ineffective social skills and impaired perceptions that often accompany personality disorder (PD) can create unique challenges in the establishment of a therapeutic nurse-client relationship. For clients who struggle with trust issues, an unplanned admission to a hospital or treatment center can exacerbate anxiety and sense of mistrust. Consistency with client care—including demonstration of respect for the client at all times—is one of the first steps to building trust. Once the relationship has been established, the nurse should encourage client feedback as part of continuing care. Limiting contact with others and being available to meet all the needs of the client would not build a therapeutic relationship.

The nurse is obtaining a prenatal intake for a pregnant client with a history of kidney stones. Which measure should the nurse instruct the client to take to prevent further kidney stones from forming? A) "Decrease dietary calcium intake." B) "Empty the bladder frequently." C) "Collect and strain all urine." D) "Increase fluid intake to 2500-3500 mL per day."

D Rationale: Measures to prevent further kidney stones include increasing fluid intake to 2500-3500 mL per day. Collecting and straining urine is only necessary if the client is diagnosed with a kidney stone. Emptying the bladder frequently prevents urine stasis, which is a contributing factor for UTIs. Dietary calcium intake is important for fetal growth, and the type of stone should be identified prior to recommending dietary changes.

The nurse is caring for a client diagnosed with struvite urinary calculi (staghorn stones). Which condition should the nurse consider as the cause? A) Genetic defect B) Excess dietary intake of calcium C) Excess of uric acid D) Bacterium associated with a UTI

D Rationale: Struvite urinary calculi are associated with the bacterium Proteus that is the cause of certain UTIs. Calcium oxalate and calcium phosphate stones are associated with excess dietary intake of calcium. Uric acid stones and stones comprised of calcium are associated with a genetic defect. Uric acid stones are associated with excess uric acid.

Which nursing goal is appropriate for a client who is admitted to the hospital with urinary calculi? A) The client will consume at least 30% of the prescribed diet while hospitalized. B) The client will rate the pain at 5 on a 0-10 scale in 20 minutes after receiving IV morphine. C) The client will receive 80% of fluids while hospitalized. D) The client will maintain urine output of 2500 mL/24 hours while hospitalized.

D Rationale: The client admitted to the hospital with urinary calculi will maintain urinary output of 2500 mL/24 hours while hospitalized. The client should receive 100% of fluids and consume at least 50% of the prescribed diet while hospitalized. The client's pain should be no more than a 3 on a 0-10 scale 20 minutes after receiving IV morphine.

The parents of a teenage girl bring their daughter to the healthcare provider, citing their increasing concern about the teen's weight and their suspicion that their daughter has anorexia nervosa (AN). During assessment, the nurse notes a BMI of 16.75 kg/m2. In which category does the client fall, according to DSM-5 criteria and considering the severity of anorexia nervosa? A) Mild B) Extreme C) Severe D) Moderate

D Rationale: The DSM-5 identifies BMI as an important clinical indicator of the severity of AN. A BMI of 16.75 kg/m2 would be classified as moderate category anorexia. A BMI of 17 kg/m2 or greater is categorized as mild anorexia. A BMI of 15 to 15.99 kg/m2 is categorized as severe. A BMI of less than 15 kg/m2 is considered to represent extreme anorexia.

The nurse teaches the parents of young adults who are taking selective serotonin reuptake inhibitors (SSRIs) for a personality disorder (PD). Which information should the nurse include regarding this medication group? A) Possible chest pain B) Difficulty breathing C) Paranoia D) Increased suicidal ideation

D Rationale: With adolescents and young adult clients, the nurse needs to make sure that the client and the family or support persons know that SSRIs carry an FDA black box warning regarding increased suicidality for that age group and are aware of the warning signs of increased suicidal ideation. Possibility of a chest pain, difficulty in breathing, and paranoia are not the possible side effects of this medicine.

The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that: a. Fluid and food will be withheld the morning of the examination. b. A tranquilizer will be given before the examination. c. An enema will be given before the examination. d. No special preparation is required for the examination.

D A KUB radiographic examination ordinarily requires no preparation. It is usually done while the client lies supine and does not involve the use of radiopaque substances.

The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect? a. Decreased urine alkaline phosphatase level. b. Increased urine calcium excretion. c. Increased serum calcium level. d. Decreased serum uric acid level.

D By inhibiting uric acid synthesis, allopurinol (Zyloprim) decreases its excretion. The drug's effectiveness is assessed by evaluating for a decreased serum uric acid concentration. Allopurinol does not alter the level of alkaline phosphatase, nor does it affect urine calcium excretion or the serum calcium level.

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? a. Do not allow the client to ingest fluids. b. Encourage the client to drink at least 500 mL of water each hour. c. Request the central supply department to send supplies for straining urine. d. Administer an opioid analgesic as prescribed.

D If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

The client is experiencing urolithiasis composed of Struvite. The nurse would teach the client that the cause of these stones is: a. calcium. b. uric acid. c. cystine. d. bacteria.

D Rationale: Most kidney stones are composed of calcium, others are from uric acid. Cystine stones are from a genetic defect whereas struvite stones originate from bacteria.

During a health history, which statement by a client indicates a risk of renal calculi? a. "I've been drinking a lot of cola soft drinks lately." b. "I've been jogging more than usual." c. "I've had more stress since we adopted a child last year." d. "I'm a vegetarian and eat cheese two or three times each day."

D Renal calculi are commonly composed of calcium. Diets high in calcium may predispose a person to renal calculi. Milk and milk products are high in calcium. Cola soft drinks don't contain ingredients that would increase the risk of renal calculi. Jogging and increased stress aren't considered risk factors for renal calculi formation.

A nurse is instructing a client with oxalate renal calculi. What foods should the nurse urge the client to eliminate from his diet? a. Citrus fruits, molasses, and dried apricots b. Milk, cheese, and ice cream c. Sardines, liver and kidney d. Spinach rhubarb and asparagus

D To reduce the formation of oxalate calculi, urge the client to avoid foods high in oxalate, such as spinach, rhubarb, and asparagus. Other oxalate- rich foods to avoid include tomatoes, beets, chocolate, cocoa, celery, and parsley. Citrus fruits, molasses, dried apricots, milk, cheese, ice cream, sardines and organ meats do NOT produce oxalate and do NOT need to be omitted from the client's diet.

A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is: a. dull and aching in the costovetebal area b. aching and camplike thoughout the abdomen c. sharp and radiating posteriorly to the spinal column d. excruciating, wavelike, and radiating toward the genitalia

D excruciating, wavelike, and radiating toward the genitalia

When a nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. You and I will have to sit down and discuss this problem. b. It bothers me to see you exercising. You'll lose more weight. c. Lets discuss the relationship between exercise and weight loss and how that affects your body. d. According to our agreement, no exercising is permitted until you have gained a specific amount of weight.

D ~ A matter-of-fact statement that the nurses perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action.

D ~ The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionism. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisiveness, submissiveness. d. grandiosity, attention seeking, and arrogance.

D ~ According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the characteristics of grandiosity, attention seeking, and arrogance are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients diagnosed with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals diagnosed with obsessive-compulsive personality disorder. Patients diagnosed with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

D ~ Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patient's concentration and attention. b. shifting the patient's focus from food to psychotherapy. c. focusing on weight control mechanisms and food preparation. d. processing the heightened anxiety associated with eating.

D ~ Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patient's focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patient's concentration and attention is important, but not the primary purpose of the schedule.

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: a. inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

D ~ Fear of abandonment is a central theme for most patients diagnosed with borderline personality disorder. This fear is often exacerbated when patients diagnosed with borderline personality disorder experience success or growth. The incorrect options are not associated with self-mutilation.

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

D ~ Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

A therapist recently convicted of multiple counts of Medicare fraud says, Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too. These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

D ~ Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patients remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention Monitor for complications of re-feeding. Which body system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

D ~ Re-feeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the re-feeding syndrome.

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. I think you are the best nurse on the unit. b. Im never going to get high on drugs again. c. I hate my doctor for not giving me what I ask for. d. I felt empty and wanted to cut myself, so I called you.

D ~ Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

D ~ Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

D ~ The correct option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

A nursing diagnosis for a patient diagnosed with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, Within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

D ~ The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

A persons spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? a. I have a quick temper, but I can usually keep it under control. b. I've done some stupid things in my life, but Ive learned a lesson. c. I'm feeling terrible about the way my behavior has hurt my family. d. I hit because I'm tired of being nagged. My spouse deserved the beating.

D ~ The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

D ~ The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient's current serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia

D ~ The patient's history and laboratory results support the correct nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

D ~ The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority above the incorrect responses.

Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping? A. Difficulty in relationships B. High levels of anxiety C. Manipulation D. Interdependence

D. Interdependence The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation. Interdependence would not be considered a symptom for ineffective coping.

A client was admitted to the hospital with cholelithiasis. Which new finding indicates to the nurse that the stone has probably obstructed the common bile duct? A. Nausea B. Elevated cholesterol level C. Right upper quadrant pain (RUQ) D. Jaundice

D. Jaundice Nausea and RUQ pain occur in cholelithiasis, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaudince.

Mrs. Smith is admitted to the emergency department of Nurseslabs Medical Center with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband, Mr. Smith, who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? A. Mrs. Smith's explanation is appropriate acceptance of her responsibility. B. Mrs. Smith's explanation is an atypical reaction of an abused woman. C. Mrs. Smith's explanation is evidence that the woman may be an abuser as well as a victim. D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.

D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.

A nurse is performing an assessment on a client admitted to the mental health unit. The client tells the nurse that she cannot leave home without checking numerous times that the iron and coffee pot have been shut off. The client states that this activity makes her late for many functions and that she misses engagements on occasion because of it. The nurse would expect to note which anxiety disorder documented in the client's record? A. A phobia B. Generalized anxiety disorder C. Posttraumatic stress disorder (PTSD) D. Obsessive-compulsive disorder (OCD)

D. Obsessive-compulsive disorder (OCD) Rationale: A repetitive behavior that interferes with activities of daily living and functioning is indicative of OCD. This repetitive behavior is not associated with phobias, generalized anxiety disorder, or PTSD.

A nurse is preparing to admit a client with a diagnosis of obsessive-compulsive disorder (OCD) to the mental health unit. The nurse would expect to note which behaviors in the client? A. Suspicious and hostile B. Flexible and adaptable C. Frightened and delusional D. Rigidness in thought and inflexibility

D. Rigidness in thought and inflexibility Rationale: Rigid and inflexible behaviors are characteristic of the client with OCD. Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion, because this behavior is what decreases the anxiety. Options 1, 2, and 3 are incorrect and are not characteristic of OCD.

The nurse is working with an adult who has been dealing with an eating disorder for the past year. The client asks the nurse about mindfulness as an approach. Which evidence concerning mindfulness should the nurse include in the response to the client? (Select all that apply.) Decreases binge eating Decreases food cravings Limits the likelihood of relapse Decreases body image concerns Promotes a more complete recovery

Decreases binge eating Decreases food cravings Decreases body image concerns Research concerning the use of mindfulness indicates that it decreases binge-eating behaviors, food cravings, and body image concerns. The use of fluoxetine is known to reduce the likelihood of relapse and cognitive-behavioral therapy promotes a more complete recovery because it is a more holistic approach.

Fill-in-the-Blank ________________________________ personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Dependent ~ Rationale: Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. These characteristics are evident in the tendency to allow others to make decisions, to feel helpless when alone, to act submissively, to subordinate needs to others, to tolerate mistreatment by others, to demean oneself to gain acceptance, and to fail to function adequately in situations that require assertive or dominant behavior.

The community health nurse discusses the risk factors for nephritis with a group of community members. Which risk factor should the nurse include in the teaching? (Select all that apply) Diabetes Drug abuse Hypotension Hypothyroidism Overuse of over-the-counter painkillers

Diabetes Drug abuse Overuse of over-the-counter painkillers Diabetes causes damage to the fragile vessels of the nephron that can result in nephritis. Drug abuse and the chronic overuse of over-the-counter painkillers increase the risk. Hypertension, not hypotension, damages the nephron to cause nephritis. Hypothyroidism is not a risk factor for nephritis.

Which statement should the nurse include in a presentation regarding eating disorders? (Select all that apply.) Eating disorders can cause malnutrition. Teenagers are the only age group with eating disorders. Excessive exercise can be associated with an eating disorder. Diet pills and laxatives are not used by people with eating disorders. Electrolyte imbalance is a common problem associated with eating disorders.

Eating disorders can cause malnutrition. Excessive exercise can be associated with an eating disorder. Electrolyte imbalance is a common problem associated with eating disorders.

Define egodystonic

Egodystonic (or ego alien) is the opposite, referring to thoughts and behaviors (dreams, compulsions, desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego, or, further, in conflict with a person's ideal self-image.

A client is suspected of having acute postinfectious glomerulonephritis. Which test result, if elevated, should lead the nurse to determine that the suspected diagnosis is correct? Creatinine clearance Antistreptolysin O (ASO) titer Blood urea nitrogen (BUN) Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate (ESR) The ESR is a general indicator of inflammatory response and may be elevated in acute postinfectious glomerulonephritis and in lupus nephritis. BUN measures urea nitrogen, the end product of protein metabolism, created by the breakdown and metabolism of dietary and body proteins. Creatinine clearance is a specific indicator of renal function used to evaluate the glomerular filtration rate (GFR). The ASO titer detects streptococcal exoenzymes.

What are the manifestations of TURP syndrome?

FLUID VOLUME OVERLOAD hyponatremia decreased htc hypertension bradycardia nausea confusion

A nurse is providing teaching on the manifestation of complications to a client who has acute glomerulonephritis. Which of the following complications should the client report to the provider? a. dry cough b. pitting edema c. wt. gain of 2 lbs in 1 week d. temp of 98.4

b. pitting edema: fluid overload a. WET cough: fluid overload c. 5 lbs in one week

The nurse assesses a client suspected of having glomerulonephritis. Which assessment finding should indicate to the nurse that the suspected diagnosis is correct? Peripheral and central cyanosis Facial and peripheral edema Decreased bowel sounds Prolonged capillary refill

Facial and peripheral edema Because renal function is impaired in glomerulonephritis, the client will exhibit facial, periorbital, and peripheral edema. Peripheral cyanosis indicates hypoxia and is a respiratory problem. Prolonged capillary refill and decreased bowel sounds are not signs of glomerulonephritis.

The nurse is counseling a teen with anorexia nervosa (AN) who is trying to manage the disorder. Which type of therapy should the nurse discuss with the client? Schema-focused therapy Dialectical behavior therapy Family therapy Daily fluoxetine therapy

Family therapy Systemic family therapy and family-based therapy are focused on family strengths and family narratives. These are often used with adolescent anorexic clients, mobilizing the family as the primary resource in feeding and restoring health to the undernourished client. Fluoxetine is approved by the FDA for use with bulimia only, not with anorexia. Schema-focused therapy and dialectical behavior therapy are used for personality disorders, not anorexia.

The nurse is caring for a client in the acute phase of postinfectious glomerulonephritis. Which intervention should the nurse implement? (Select all that apply.) Fluid restriction Parenteral nutrition Protein restriction Chest physiotherapy Bedrest

Fluid restriction Protein restriction Bedrest A client in the acute phase of postinfectious glomerulonephritis is placed on bedrest, so the body can conserve energy. Only sensible fluid loss is replaced until the renal status is known. Because of the azotemia, protein consumption is limited. Chest physiotherapy is used to clear the lungs of secretions in pulmonary diseases. Parenteral nutrition is not necessary with glomerulonephritis, as the client will still be able to eat.

What are the 2 causes of peptic ulcer disease

H. pylori NSAID use

Fill-in-the-Blank _____________________ personality disorder is characterized by colorful, dramatic, and extraverted behavior in excitable, emotional people.

Histrionic ~ Rationale: Histrionic personality disorder is characterized by colorful, dramatic, and extraverted behavior in excitable, emotional people. They have difficulty maintaining long-lasting relationships, although they require constant affirmation of approval and acceptance from others.

A client is admitted with acute postinfectious glomerulonephritis. Which medication should the nurse expect to be prescribed for the client to reduce inflammation? Angiotensin-converting enzyme (ACE) Inhibitor Antihypertensive Glucocorticoid Immunosuppressant

Immunosuppressant To control inflammation caused by acute postinfectious glomerulonephritis, the nurse will administer an immunosuppressant. A glucocorticoid also decreases inflammation. However, this medication is contraindicated in acute postinfectious glomerulonephritis. An ACE inhibitor is used in the management of this condition; however, it is used to reduce proteinuria and slow the progression of renal failure. An antihypertensive is also used in the management of this condition; however, it is used to treat hypertension.

Which problem is a priority for the nurse to address when caring for a client with acute glomerulonephritis? Impaired fluid balance Fatigue Impaired skin integrity Impaired nutrition

Impaired fluid balance While all choices are problems that should be addressed in planning care for the client diagnosed with nephritis, impaired fluid balance is a priority as this problem may be life-threatening if not addressed.

Define egosyntonic

In psychoanalysis, egosyntonic refers to the behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one's ideal self-image.

The nurse is orienting a new nurse in the inpatient care unit. Which statement should the nurse include in the orientation regarding a nurse-client relationship that would ensure effective treatment of clients with eating disorders? It is hard for clients to be open about eating disorders, so nurses must be respectful and patient and develop trust. It is best not to trust what clients tell you about their eating habits; they hide their behaviors. These clients can be very manipulative, and their behavior must be recognized so that it can be addressed immediately and effectively. Very clear structure is necessary for these clients, and avoiding opportunities for the client to split staff is absolutely crucial.

It is hard for clients to be open about eating disorders, so nurses must be respectful and patient and develop trust. Clients with eating disorders have generally been very secretive about their disorders, so it is a major challenge for them to become open about them. To support this openness, nurses must establish a therapeutic relationship based on trust, which requires patience, respect, and consistency. Though these clients can be secretive, telling the new nurse not to trust them would impede development of a therapeutic relationship. Most inpatient programs do have a structure, which is important for nurses to follow, but this does not best support the development of a therapeutic relationship with clients. Manipulative behaviors are characteristic of many mental health issues, but recognition of them does not best support effective treatment through the nurse-client relationship.

A client suspected of having nephritis is scheduled for a test at the nuclear medicine department. The client asks the nurse, "What test am I having?" Which test should the nurse identify? Renal ultrasound Renal biopsy Kidney scan Kidney, ureter, bladder (KUB)

Kidney scan The kidney scan uses nuclear medicine to visualize the kidney after intravenous administration of a radioisotope. The KUB (kidney, ureter, bladder) is an abdominal x-ray that evaluates kidney size and may rule out other causes. The renal ultrasound does not use nuclear medicine. The renal biopsy is a microscopic examination of kidney tissue and does not use nuclear medicine.

A client with an eating disorder has been hospitalized for medical stabilization. Which intervention should the nurse include to address energy expenditure? Monitoring cardiovascular and respiratory response to activity Limiting the client's activity and restricting exercise Monitoring vital signs and electrolyte levels Eliminating caffeine and other stimulants from the client's diet

Limiting the client's activity and restricting exercise In clients with eating disorders who are hospitalized for medical stabilization, it is important to limit activity and manage energy expenditure. Monitoring of vital signs, electrolyte levels, and cardiovascular/respiratory responses to exercise may also be included, but these interventions do not directly address energy expenditure. Eliminating caffeine and other stimulants from the client's diet can help decrease anxiety but does not directly address energy expenditure. OK

The nurse is discussing ways to prevent the development of nephritis with a client. Which strategy should the nurse include? Cutting down on smoking Maintaining blood pressure control Maintaining good dental hygiene Practicing stress-reduction techniques

Maintaining blood pressure control While the exact cause of nephritis is unknown, maintaining good blood pressure control (controlling hypertension) is one way to prevent damage to the kidneys and reduce the incidence of nephritis. Quitting smoking, not cutting down, is recommended. Good dental hygiene and reducing stress are not associated with the risk of developing nephritis.

When planning care for a client with acute glomerulonephritis, the nurse should prioritize which intervention? (Select all that apply.) Maintaining fluid balance Promoting an adequate sleep pattern Using standard precautions Maintaining skin integrity Promoting nutritional balance

Maintaining fluid balance Using standard precautions Maintaining skin integrity Promoting nutritional balance Interventions for a client with acute glomerulonephritis primarily focus on preventing infection, maintaining skin integrity, promoting nutritional balance, and maintaining fluid balance. Promoting an adequate sleep pattern may be an appropriate intervention; however, this is not a primary focus for this client.

The nurse planning care for a client diagnosed with nephritis assigns a goal of maintaining fluid volume balance. Which intervention should the nurse include in the client's plan of care? (Select all that apply.) Measuring abdominal girth Providing a low-sodium diet Encouraging fluid intake Offering ice chips frequently Keeping sheets tight and wrinkle-free

Measuring abdominal girth Providing a low-sodium diet Offering ice chips frequently The client diagnosed with nephritis will be on a fluid restriction diet. Fluids are restricted, not pushed. Measuring abdominal girth allows the nurse to monitor the degree of ascites. Offering frequent ice chips is a means to relieve thirst. Providing a low-sodium diet will decrease fluid retention by the kidneys. Keeping sheets tight and without wrinkles helps to promote skin integrity.

Moderate The DSM-5 identifies BMI as an important clinical indicator of the severity of AN. A BMI of 16.75 kg/m2 would be classified as moderate category anorexia. A BMI of 17 kg/m2 or greater is categorized as mild anorexia. A BMI of 15 to 15.99 kg/m2 is categorized as severe. A BMI of less than 15 kg/m2 is considered to represent extreme anorexia.

What is the primary diagnostic criteria for anorexia nervosa? a. Sense of lack of control over eating. b. Woman has amenorrhea for two months. c. Fear of being overweight when body mass index is < 18.5. d. Person engages in episodes of fasting or excessive exercise of >1 ½ hours per day.

The healthcare provider has diagnosed a binge-eating disorder in a client. Which common complication of this disorder requires further testing? (Select all that apply.) Obesity Osteoporosis Heart disease Type 2 diabetes Gallbladder disease

Obesity Heart disease Type 2 diabetes Gallbladder disease Clients found to have binge-eating disorder should undergo a full physical examination to screen for complications of the illness, including obesity, heart disease, type 2 diabetes, and gallbladder disease. Osteoporosis is a complication of anorexia nervosa, not binge-eating disorder.

Fill-in-the-Blank _____________________ personality disorder is a pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent.

Paranoid ~ Rationale: Paranoid personality disorder is a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This disorder begins in early adulthood and presents in a variety of contexts.

The nurse instructs a pregnant client diagnosed with nephritis about the possible effects of nephritis on the pregnancy. Which should the nurse include in the teaching? (Select all that apply.) Preeclampsia Abruptio placenta Preterm delivery Fetal loss Infant with low birthweight

Preeclampsia Preterm delivery Fetal loss

What are the 3 risk factors for BPH

Presence of testes Age: older than 40 Race: black/hispanic earlier than whites and asian later than whites

What are the 6 manifestations for cholecystitis

RUQ pain that radiates to the back, right scapula and shoulder nausea vomiting anorexia RUQ tenderness/guarding fever/chills

What are the 3 manifestations for cholelithiasis

RUQ pain that radiates to the back, right scapula, and shoulder nausea vomiting

A client is hospitalized for anorexia nervosa. The client's BMI on admission is 14.8 kg/m2. The client has been started on an antidepressant, cognitive-behavioral therapy (CBT), and a weight-restoration plan. Monitoring for which possible complication should be a priority for the nurse as the client begins eating again? Refeeding syndrome Increased depression Purging Edema

Refeeding syndrome The nurse should monitor the client for refeeding syndrome, which is dangerous and a potentially fatal condition that can occur when clients who are severely malnourished begin eating again. The other items are not as serious of priorities as refeeding syndrome.

What are the 3 goals of kidney stone treatment?

Relieving acute symptoms (pain/dehydration) destroying or removing the stones prevent further stone formation

Fill-in-the-Blank _______________________ personality disorder is characterized by a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way.

Schizoid ~ Rationale: Persons diagnosed with schizoid personality disorder have a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way. These individuals display a life-long pattern of social withdrawal, and their discomfort with human interaction is apparent.

The client with cholelithiasis is scheduled for a cholangiogram and the nurse instructs the client about the test. The nurse determines that the client understands the purpose of the test when the client states: a. "They will flush my gallbladder." b. "A medication to prevent stones will be placed in my gallbladder." c. "My gallbladder and ducts will be checked." d. "The procedure will drain the gallbladder."

c. check gallbladder and ducts

The nurse admits a client diagnosed with glomerulonephritis. The nurse should identify which characteristic that occurs with glomerulonephritis? (Select all that apply.) Slow, progressive destruction of the glomeruli Surfaces of the kidneys becoming soft and boggy Symmetrical decrease in the size of the kidneys Entire nephrons eventually being lost Gradual decline in renal function

Slow, progressive destruction of the glomeruli Symmetrical decrease in the size of the kidneys Entire nephrons eventually being lost Gradual decline in renal function Characteristics of chronic glomerulonephritis include a slow, progressive destruction of the glomeruli, a gradual decline in renal function, a symmetrical decrease in the size of the kidneys, and an eventual loss of the entire nephron. The surfaces of the kidneys become granular or roughened, not soft and boggy.

A client presents at the urgent care clinic and states, "My heart feels like it's skipping beats." The client also reports always feeling cold, and has a BMI of 18. The nurse suspects anorexia. Which other clinical manifestation should the nurse assess? (Select all that apply.) Strenuous exercise Feelings of euphoria Extreme perfectionism Obsession over body shape Rigidity and the need to control situations

Strenuous exercise Extreme perfectionism Obsession over body shape Rigidity and the need to control situations Clinical manifestations of anorexia nervosa include obsession with body shape; obsession with food; extreme perfectionism; rigidity and the need to control situations; and over-exercise. Depression, not euphoria, is also a common manifestation.

What is the difference between a TURP and a TUIP?

TURP - tissue is cut out TUIP - tissue is moved away from the urethra

The nurse is caring for a client diagnosed with nephritis. Which assessment finding on discharge leads the nurse to determine that treatment was successful? The client's temperature is 101.5°F. The client has regained urine output. The client has gained less than 5 pounds. The client's sodium level is 150 mEq/L.

The client has regained urine output. Successful treatment of nephritis is evidenced by the client maintaining or regaining a normal urine output. The client's weight should return to the pre-admission weight as all retained fluid is excreted. An elevated temperature indicates that the client might be experiencing an infection. The client's sodium level should return to normal levels (135-145 mEq/L).

The nurse is preparing a plan of care for a client whose anorexia nervosa is complicated by dehydration and a cardiac arrhythmia. Which outcome should the nurse consider positive for this client? (Select all that apply.) The client remained free of injury. The client increased nutritional intake by 20%. The client had a 24-hour fluid intake of 600 mL. The client attended therapy sessions as scheduled. The client stated that she liked how she looked in the new dress.

The client remained free of injury. The client increased nutritional intake by 20%. The client attended therapy sessions as scheduled. The client stated that she liked how she looked in the new dress. Positive outcomes for clients with an eating disorder include remaining free of injury, increasing nutritional intake, viewing themselves positively, and attending therapy on a consistent schedule. A fluid intake of 600 mL/day is insufficient.

The nurse is reviewing a questionnaire completed by an adolescent client. Which predisposing factor may increase the client's risk for an eating disorder? (Select all that apply.) The client reports a history of childhood abuse. The client's mother has a history of bulimia nervosa. The client lists alprazolam (Xanax) on the home medication list. The client lists "checkout clerk in a grocery store" as the occupation. The client reports good family support and a healthy friendship network

The client reports a history of childhood abuse. The client's mother has a history of bulimia nervosa. The client lists alprazolam (Xanax) on the home medication list. Familial risk factors for an eating disorder include a history of physical or sexual abuse or a genetic predisposition to an eating disorder. Anxiety requiring a prescription for alprazolam (Xanax) may be a psychological factor in the development of an eating disorder. Working in a grocery store, good family support, and a healthy friendship network are not risk factors.

The nurse and a client with an eating disorder have set up a behavioral contract to guide the client toward healthier eating patterns. Which goal should be incorporated in the contract? (Select all that apply.) The client will not engage in purging behaviors. The client will maintain adequate calorie intake. The client will attend and participate in therapy. The client will limit exercise to 30 minutes per day. The client will stop compulsive thinking about weight.

The client will not engage in purging behaviors. The client will maintain adequate calorie intake. The client will attend and participate in therapy. The client will limit exercise to 30 minutes per day. As part of an inpatient program for eating disorders, a behavioral contract may involve refraining from purging behaviors, maintaining adequate caloric intake, avoiding excessive exercise, and participating in therapy as part of the treatment program. Clients with eating disorders may not be able to control or stop their compulsive thoughts, so including thought stopping as a goal in the behavioral contract is not realistic.

A client is brought to the emergency department after being found unconscious by her daughter. The daughter reports that her mother has been struggling with eating disorders for "as long as I can remember" and has been in and out of treatment programs for bulimia nervosa. Which test should the nurse expect the healthcare provider to order? (Select all that apply.) Urinalysis Electrocardiography (ECG) Blood glucose monitoring Computerized tomography (CT) scan Comprehensive metabolic panel (CMP)

Urinalysis Electrocardiography (ECG) Blood glucose monitoring Comprehensive metabolic panel (CMP) Electrolyte imbalances are common in clients with eating disorders. A CMP is necessary to learn whether serum potassium is decreased, which could cause cardiac arrhythmias. Blood glucose monitoring may indicate hypoglycemia or diabetic ketoacidosis if the client is purging or diabetic. Electrocardiography is used to detect any cardiac arrhythmias resulting from electrolyte imbalances; some arrhythmias associated with eating disorders are fatal. Urinalysis indicates the presence of ketones. A CT scan is not indicated for clients with eating disorders.

Yoga Massage Meditation Acupuncture Yoga, massage, acupuncture, and meditation are all potential complementary therapies for clients with eating disorders. Because of their laxative and weight loss effects and the potential for abuse, herbs are not typically used in the treatment of eating disorders.

A 36-year-old mother of six has been recently diagnosed with type 2 diabetes. She reports increased hunger and food consumption while continuing to lose weight. What is the term used to describe this condition? a. Polyphagia b. Polydipsia c. Polyuria d. Anorexia

A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this need as reflecting which of the following? a. Physiology b. Safety and security c. Esteem and self-respect d. Belongingness and affection

A client struggling with a binge eating disorder tells a nurse, "I don't know why I eat the way I do each night." What question would be most helpful for the nurse to ask this client? a. "What do you do when you feel stressed or upset?" b. "Do you worry that bad things will happen to you?" c. "Are there periods of time at night that you can't account for?" d. "Have you experienced changes in your leisure activities?"

A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? a. Providing one-on-one supervision during meals and for one hour afterward b. Letting the client eat with other clients to create a normal mealtime atmosphere c. Trying to persuade the client to eat and thus restore nutritional balance d. Giving the client as much time to eat as desired

A nurse is working in a school health program that provides care to elementary school-aged children. The nurse would focus teaching on which area as being most problematic? a. Injuries b. Substance Abuse c. Eating Disorders d. Sexually Transmitted Disorders

During her first prenatal visit, a client expresses concern about gaining weight. What is the nurse's first action? a. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. b. Be alert for a possible eating problem and do a further in-depth assessment. c. Report the client's concerns to her caregiver. d. Ask her to come back to the clinic every 2 weeks for a weight check.

Which serum sodium level in an elderly man with anorexia may cause convulsions or coma? A. 135 mEq/L B. 145 mEq/L C. 140 mEq/L D. 142 mEq/L

A client with BPH has been started on Proscar (finasteride). The nurses discharge teaching should include: a. telling the clients wife not to touch the tablets b. explaining the medication should be taken with food c. telling the client symptoms will improve in 1-2 weeks d. instructing the client to take the medication at bedtime to prevent nocturia.

a ( finasteride is an androgen inhibitor, therefore women who are pregnant or may become pregnant should be told to avoid touching the tablets.. Answer b is incorrect because there are no benefits to giving the med with food. Answer c is incorrect because it can take 6 months to a year to be effective. Answer d is not an accurate statement.)

Continuous bladder irrigations are ordered for a pt following TURP. The purpose of continuous bladder irrigations is to: a. prevent formation of blood clots b. administer intravesical medication c. prevent post operative pain d maintain bladder tone

a (Continuous bladder irrigation are ordered following TURP to prevent blood clots from forming and blocking the catheter. )

A nurse is instructing a client who is scheduled for TURP about his post operative care. Which of the following information should the nurse include in the teaching? a. you may have a continuous sensation of needing to void even though you have a catheter. b. you will be on bed rest for the first 2 days after the procedure c. you will be instructed to limit your fluid intake after the procedure d. your urine should be clear yellow the evening after the surgery

a (to reduce the risk of post op bleeding the client will have a catheter with a large balloon that places pressure on the internal sphincter of the bladder. Pressure on the sphincter causes a continuous sensation of needing to void)

A nurse is working with a client with bulimia. Which goals should be included in the care plan? Select all that apply. a. The client will maintain normal weight. b. The client will comply with medication therapy. c. The client will achieve a positive self-concept. d. The client will acknowledge the disorder. e. The client will never have the desire to purge again.

a, b, c, d

During the nurse's assessment of a client who has been diagnosed with bulimia nervosa, the nurse evaluates certain assessment findings that accompany binge eating. Which are most applicable? Select all that apply. a. Guilt b. Dental Caries c. Self-induced vomiting d. Weight loss e. Normal weight f. Introverted behavior

a, b, c, e

A teenage client is admitted to the psychiatric unit with both bulimia nervosa and anorexia nervosa. Which initial interventions are appropriate for this client? Select all that apply. a. Assign a staff member to accompany the client when using the bathroom. b. Have the client keep a self-monitoring journal as a coping strategy. c. Weigh the client in same amount of clothing and facing away from scale readout at daily scheduled intervals (e.g., 0645 on Tuesdays and Fridays). d. Inform the client that parenteral nutrition will be necessary if the client does not gain weight. e. Assign a staff member to sit with client during meals and for 1½ hour after meals. f. Provide liquid protein supplements when client is unable to eat meals.

a, b, c, e, f

A nurse is caring for an anorexic client with a nursing diagnosis of imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client? Select all that apply. a. Provide small, frequent meals b. Monitor weight gain c. Allow the client to skip meals until the antidepressant levels are therapeutic. d. Encourage the client to keep a journal. e. Monitor the client during meals and for 1 hour after meals. f. Encourage the client to eat three substantial meals per day. g. Encourage the client to talk about non-food-related topics during mealtimes.

a, b, d, e, g

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. a. Clients must eat within view of a staff member. b. Clients are not told their weight and cannot see their weight while being weighed. c. Clients are not allowed to discuss food or eating in groups or informal conversation with peers. d. Clients must rest within view of a staff member for one half hour to an hour after eating. e. Clients may not go to the bathroom for one-half hour to an hour after eating. f. Clients cannot participate in any groups after admission until they gain one pound (0.5 kg). g. Collaborate with nutritional counselors and dieticians at the hospital.

a, b, d, e, g

A client with mild benign prostatic hyperplasia (BPH) tells the nurse that he prefers to do things open double quote"naturallyclose double quote" and doesn't want to take medication for his condition. He asks her if there are some things he can do to help his BPH without drugs. Which lifestyle changes used in the treatment for BPH would the nurse include in the response to the client? (Select all that apply.) a Reducing stress b Exercising regularly, including Kegel exercises c Avoiding alcohol and caffeine d Avoiding drinking fluids within 2 hours of bedtime e Increasing dietary intake of foods high in potassium

a,b,c,d (Rationale Lifestyle changes that may help clients with mild BPH include avoiding alcohol and caffeine, exercising regularly, including Kegel exercises, avoiding drinking fluids within 2 hours of bedtime, and reducing stress. Dietary intake of potassium is not related to BPH symptoms.)

The client has been prescribed dutasteride (Avodart) for benign prostatic hyperplasia (BPH). Which potential adverse effects would the nurse include in the medication teaching for this medication? (Select all that apply.) a Impotence b Decreased volume of ejaculate c Gynecomastia d Decreased libido e Renal insufficiency

a,b,d (Rationale Side effects of 5-alpha reductase inhibitors, such as dutasteride (Avodart) and finasteride (Proscar), may include impotence, decreased libido, and decreased volume of ejaculate. Gynecomastia and renal insufficiency are not side effects for these medications.)

A client with BPH has undergone TURP. Which nursing interventions are parts of the clients post-operative care? Select all that apply a. monitoring vital signs b. maintaining constant bladder irrigation c. limiting fluid intake to 1000 mL per day d. checking for postoperative bleeding e. maintaining bed rest for 48 hrs.

a,b,d (The client should increase fluid intake over 1000 mL/day; therefore c is incorrect. The client is not restricted to bed and should be encouraged to ambulate; therefore e is incorrect.)

A client underwent a transurethral resection of the prostate (TURP) 24 hours ago. The nurse providing care for him would be especially vigilant in observing for which complications? (Select all that apply.) a Decreased urinary output b Hypotension c Hypertension d Hemorrhage e Large blood clots

a,b,d,e (Rationale During the first 24dash-48 hours after a TURP, the client should be monitored closely for hemorrhage (frankly bloody urine output), the presence of large blood clots, decreased urinary output, increased bladder spasms, decreased hemoglobin and hematocrit, tachycardia, and hypotension. Hypertension would not be an expected complication.)

A client is being discharged home 3 days post. TURP. What should the nurse instruct the client to do? Select all that apply a. drink at least 3000 mL of water per day b. increase calorie intake by eating 6 small meals a day c. report bright red bleeding to the HCP d. Take a deep breathe and cough every two hours e. report temp over 99 F (37.2 C)

a,c,e (The nurse should instruct the client to drink about 3000 mL day. to keep the urine clear. The urine should be almost without color. About 2 weeks after turp when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the HCP or go the ER if at any time the urine turns bright red. The nurse should also instruct the client to report signs of infection. The client is NOT at risk for nutritional problems after TURP and can resume D.A.T. The client is not at specific risk for airway problems because the procedure is done under spinal anesthesia and the client does not need to take deep breaths and cough.)

A nurse is teaching a client who has a duodenal ulcer and a new Rx for esomprazole (Nexium). Which of the following should be included in the teaching? (select all) a. take 1 hour before a meal b. limit NSAIDs c. expect skin flushing d. increase fiber intake e. chew the medication before swallowing

a. 1 hour before meals b. limit NSAIDs e. swallow the capsule whole, do not crush or chew

A client with a duodenal ulcer asks the nurse why antibiotics are a part of the treatment plan. Which information should the nurse include in the explanation? a. Most duodenal ulcers are caused by Helicobacter pylori. b. Antibiotics are used to sterilize the stomach. c. Many people have Clostridium difficile, which can lead to ulcer formation. d. Antibiotics decrease the likelihood of infection.

a. H. pylori

The nurse is explaining to a client with benign prostatic hyperplasia (BPH) the diagnostic tests that are used to differentiate BPH from prostate cancer. The nurse includes which of the following in the explanation? (Select all that apply.) a. PSA level b. Blood chemistry c. Sperm count d. Digital rectal examination e. Pelvic ultrasound

a. PSA level d. DRE In a digital rectal examination for BPH, the prostate is asymmetrical and enlarged; in prostate cancer, the exam shows nodules and a fixed position. PSA is specific to the prostate and is released by both benign and malignant cells; however, in BPH the amounts of the free form of PSA and complex PSA would be different. The other tests are not helpful in distinguishing cancer from BPH.

The nurse is caring for a client diagnosed with a glomerular disorder. During teaching, the nurse tells the client that the disorder is a secondary form of the disease related to which of the following? a. Systemic lupus erythematosus (SLE) b. Azotemia c. Acute proliferative glomerulonephritis d. Goodpasture's syndrome

a. SLE Diseases such as SLE and diabetes mellitus cause glomerular disease secondary to SLE and diabetes. Azotemia is a symptom, not a cause, of glomerular disorders. Acute proliferative glomerulonephritis and Goodpasture's syndrome are primary disease processes.

A nurse is instructing a client who is scheduled for a TURP about his postoperative care. Which of the following information should the nurse include in the teaching? a. you may have a continuous sensation of needing to void even though you have a catheter b. you will be on bed rest for the first 2 days after the procedure c. you will be instructed to limit your fluid intake after the procedure d. your urine should be clear yellow the evening after the surgery.

a. a catheter is placed after the procedure to reduce the risk of posts bleeding b. EARLY ambulation c. INCREASE fluids d. pink urine for 24 hours

The physician has ordered omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 gram daily for a client with peptic ulcer disease (PUD). It is most important for the nurse to instruct the client to: a. Stop the drugs and notify the physician if a rash, hives, or itching develops. b. Take the drugs on an empty stomach, 1 hour before breakfast and at least 2 hours after dinner. c. Take the drugs with a full glass of water. d.Consume 8 oz of yogurt or buttermilk daily while on the medication.

a. anaphylaxis Rash, hives, and itching indicate a hypersensitivity reaction and need to be reported immediately. Consuming yogurt and taking the drugs on an empty stomach with a full glass of water are also taught to the client but are not as important as a hypersensitive reaction, which can lead to anaphylaxis and death.

A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? a. brownie with nuts b. bowl of mixed fruit c. grilled turkey d. baked potato

a. brownie: foods high in fat

The nursing is planning care for the child with glomerulonephritis and teaches the family which of the following interventions of care? a. Provide the child with ample rest and quiet activities b. Promote exercise and physical activity c. Encourage visitation with friends d. Force intake of oral fluids

a. child will be fatigued

Amanda's mobile home was destroyed by a tornado. Amanda received only minor injuries but is experiencing disabling anxiety in the aftermath of the event. What is this type of crisis called? a. crisis resulting from traumatic stress b. maturational or developmental crisis. c. dispositional crisis. d. crisis of anticipated life transitions.

a. crisis resulting from traumatic stress

A child has been admitted with acute glomerulonephritis. All of the following tests are positive for AGN. The nurse concludes that which laboratory test is most indicative of this disease? a. elevated antistreptinolysin O titers b. elevated erythrocyte sedimentation rate c. presence of hematuria according to u/a d. elevated creatinine concentrations

a. elevated antistreptinolysin O titers shows the presence of a strep infection

A nurse is assessing a client who has a dx of acute glomerulonephritis. Which of the following is an expected finding? (select all) a. fever b. peripheral edema c. polyuria d. dyspnea e. proteinuria

a. fever: possible streptococcus infection b. peripheral edema: sodium retention d. dyspnea: pulmonary edema or CHF e. proteinuria: loss of protein in the glomeruli

A client with acute nephrotic syndrome asks the nurse how the disease will be treated. The nurse tells the client that treatment will likely include: (Select all that apply.) a. Glucocorticoids. b. Plasmapheresis. c. ACE inhibitors. d. Dialysis. e. Digoxin for renal failure.

a. glucocorticoids c. ACE inhibitors Glucocorticoids such as prednisone are used to induce remission in nephrotic syndrome. ACE inhibitors are use to reduce protein loss in the urine. Digoxin is a cardiac medication. Plasmapheresis is used to treat Goodpasture's syndrome, and dialysis is used for renal failure.

Jenny reported to the high school nurse that her mother drinks too much. She is drunk every afternoon when Jenny gets home from school. Jenny is afraid to invite friends over because of her mother's behavior. The most appropriate nursing intervention with Jenny would be to a. make arrangements for her to start attending Alateen meetings. b. help her identify the positive things in her life and recognize that her situation could be a lot worse than it is. c. teach her about the effects of alcohol on the body and that it can be hereditary. d. refer her to a psychiatrist for private therapy to learn to deal with her home situation.

a. make arrangements for her to start attending Alateen meetings.

For which of the following clients with PUD is misoprostol (Cytotec) contraindicated? a. 27 y/o who is preggos b. 75 y/o who has osteoarthritis c. 37 y/o who has a kidney stone d. 46 y/o who has a UTI

a. misoprostol can induce labor

During the assessment of a client's kidneys, the nurse is unable to palpate the organs from the back of the client. What does this finding suggest to the nurse? a. Nothing, as it is a normal finding. b. The client's kidneys are misplaced. c. The client's kidneys are misshapen. d. The client's kidneys have atrophied.

a. normal finding

A nurse is in the ED is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following are expected findings? select all a. rigid abdomen b. tachycardia c. elevated BP d. circumoral cyanosis e. rebound tenderness

a. ridgid abdomen b. tachycardia e. rebound tenderness c. HYPOTENSION

When providing care for a client with glomerular disorders, the nurse teaches the client which of the following? a. "Healing takes a long time, so you will learn self-management." b. "You will be cured when you leave the hospital." c. "You will be free of infection in the future." d. "You will face activity restrictions for the rest of your life."

a. self-management The client with glomerular disorders faces a healing process that may last years. Since hospitalization for that long a time is not necessary or reasonable, the nurse will teach the client how to manage the process at home. The client is not cured when discharged from the hospital. Some clients may never recover; however, activity restrictions will be based on individual tolerance and are not universally required. No client is ever free of infection.

The nurse is preparing to care for a child with suspected glomerulonephritis. Which historical data collected on admission would support a diagnosis of acute glomerulonephritis? a. The child was treated for streptococcus 2 weeks ago. b. The child experienced a hypersensitivity reaction yesterday. c. The child had nausea and vomiting virus one week ago. d. The child fell from a bike, landing on the left side.

a. strep infection

A nurse is monitoring a client who is receiving plasmapheresis. Which of the following should indicate to the nurse that the client is experiencing side effects from the procedure? (select all) a. HR 140/min b. vertigo c. muscle cramps d. BP 90/56 e. tinnitus

a. tachycardia: sign of hypovolemia caused by the removal of blood plasma b. vertigo: sign of hypovolemia c. muscle cramping: sign of tetany (spasms) caused by the decrease of calcium within the plasma d. hypotension: sign of hypovolemia

What is the most important prevention factor

adequate fluid intake

What are the 9 risk factors for gallbladder disease

age family history race/ethnicity (native americans/hispanics) obesity hyperlipidemia rapid weight loss females using oral contraceptives biliary stasis diseases

What are the two classifications of drugs used to treat BPH?

alpha-adrenergic blockers alpha-reductase inhibitors

In a DRE, what would be indicative for BPH?

asymmetrical and enlarged prostate

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started one month after the death of his spouse. Which nursing diagnosis is most appropriate for this client? a. Activity Intolerance b. Complicated Grieving c. Ineffective Role Performance d. Low Self-Esteem

A client with a diagnosis of anorexia nervosa is admitted to the psychiatric unit. Although she is 5′ 8″ (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client? a. Teach the client about nutrition, calories, and a balanced diet. b. Establish a trusting relationship with the client. c. Discuss cultural stereotypes regarding thinness and attractiveness. d. Explore the reasons why the client doesn't eat.

In discussing home care with a client after TURP the nurse should teach the male client that dribbling of urine : a. can be a chronic problem b. can persist for several months c. is an abnormal sign that requires intervention d. is a sign of healing within the prostate

b (Dribbling can occur for several months after TURP. the client should be informed this is expected and NOT abnormal. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temp incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing but is related to the trauma of surgery.)

The nurse is caring for a man who has returned to the unit from the recovery room following a transurethral resection of the prostate (TURP). His urinary drainage bag is filled with dark red fluid with obvious clots. He is having painful bladder spasms. What would the nurse do first? a Administer pain medication in the form of a suppository. b Report the assessments to his urologist. c Assess his intake and output since surgery. d Nothing, because these manifestations are expected following a TURP.

b (Rationale: The nurse should notify the surgeon. Dark red fluid with obvious clots and painful bladder spasms could indicate that the client may be hemorrhaging postoperatively; the doctor will need to know this to direct the next actions needed to keep the client safe. The other answers do not address the need for appropriate action.)

The nurse is evaluating the effectiveness of the medical treatment of a client with BPH and determines it has been effective based on which finding? a The client has been able to maintain sexual function since beginning treatment. b The client has had no urinary tract infections since beginning treatment. c The client reports his urine is clear dark amber in color. d The client reports he has remained active and plays golf once a week.

b (Rationale: The goal of medical treatment is to promote urine flow to prevent complications such as urinary tract infections, hydronephrosis, or other results of obstructed urine flow, so lack of urinary tract infections would be a positive outcome indicating the treatment is working. While sexual function is of concern to the medical team, sexual performance is not the goal of treatment. Physiological needs always are the priority. Clear dark amber color is abnormal; the color should be clear and light yellow. BPH does not affect activity or golf.)

A client struggling with a binge eating disorder tells a nurse, "I don't know why I eat the way I do each night." What question would be most helpful for the nurse to ask this client? a) "Have you experienced changes in your leisure activities?" b) "What do you do when you feel stressed or upset?" c) "Do you worry that bad things will happen to you?" d) "Are there periods of time at night that you can't account for?

b) "What do you do when you feel stressed or upset?"

The home health nurse is caring for a client receiving chemotherapy. The client reports anorexia and has a weight loss of 15 pounds (6.8 kilograms) over 6 weeks. Which client teaching would be helpful? Select all that apply. a. Eat large meals when hungry b. Obtain calorie dense foods for snack c. Cook a hot meal for lunch and dinner d. Have family prepare and deliver favorite meals e. Eat small portions of each food group f. Eat slowly and in a relaxed atmosphere

b, d, e, f

The nurse is working with a client with an eating disorder. The nurse is assessing for compensatory behaviors. What questions indicate purging/non-purging compensatory behaviors? Select all that apply. a. Separating food b. Use of laxatives c. Eating slowly d. Excessive Exercise e. Fasting f. Use of diuretics g. Sneaking food

b, d, e, f

A nurse is providing discharge instructions to a client who is post op following TURP. Which of the following instructions should the nurse include? a. avoid sexual intercourse for 3 months after the surgery b. if urine appears bloody stop activity and rest c. avoid drinking caffeine d. take a stool softner daily e. treat pain with ibuprofen

b,c,d (provider instructs avoid sex typically 2-6 weeks, avoid non steroidal anti-inflammatory drugs because they cause bleeding. )

A HCP has prescribed amoxicillin 100 PO two times a day. What should the nurse instruct the client to do? Select all that apply a. drink 300-500 mL daily b. Void frequently, at least every 2-3 hours c. take time to empty the bladder completely. d. take the last dose of antibiotic for the day at bed time. e. take the antibiotic with or without food

b,c,d,e (Amox may be given with or without food, but the nurse should instruct the client to obtain adequate fluid intake, 2500-3000 mL to promote urinary output and to flush out bacteria from the urinary tract. The nurse should also encourage the client to void freq. every 2-3 hrs. and empty the bladder completely. Taking the antibiotic at bed time after emptying the bladder helps to ensure adequate concentration of the drug during the overnight period)

A client who has just undergone transurethral resection of the prostate (TURP) has developed TURP syndrome, according to the healthcare provider. Which findings during the nursing assessment support this diagnosis? (Select all that apply.) a Hypotension b Decreased hematocrit c Confusion d Hypertension e Hyponatremia

b,c,d,e (Rationale TURP syndrome occurs when the client absorbs the irrigation fluids during and after surgery. Clinical manifestations are hyponatremia, decreased hematocrit, hypertension, bradycardia, nausea, and confusion. If not treated promptly, TURP syndrome may result in dysrhythmias and/or seizures. Hypotension is not a manifestation of this syndrome.)

A client is admitted to the hospital for elective knee surgery to be performed the following day. The client tells the nurse that he has benign prostatic hyperplasia (BPH). Which assessment findings support the diagnosis of BPH? (Select all that apply.) a Fever b Nocturia c Elevate white blood cell (WBC) count d Urinary frequency e Increased time to void

b,d,e (Rationale Clinical manifestations of BPH include weak urinary stream, increased time to void, hesitancy, incomplete bladder emptying, postvoid dribbling, frequency, urgency, incontinence, nocturia, dysuria, and bladder pain. Fever and an elevated WBC count are not signs of BPH.)

A nurse in a providers office is obtaining a history from a client who is undergoing an evaluation for BPH. The nurse should identify that which of the following findings are indicative of this condition? select all that apply a. backache b. frequent uti c. weight loss d. hematuria e. urinary incontinence

b,d,e (a: backache occurs in prostate cancer that has spread, c: indication of prostate cancer, b: in presence of BPH pressure on urinary structures leads to urinary stasis, which promotes recurrence of UTI's. D: hematuria occurs with BPH E: overflow incontinence occurs with BPH due to increased volume of residual urine.)

The nurse is explaining to a client with benign prostatic hyperplasia (BPH) the diagnostic tests that are used to differentiate BPH from prostate cancer. Which would the nurse include in the explanation? (Select all that apply.) a Blood chemistry b Digital rectal examination c Pelvic ultrasound d Sperm count e PSA level

b,e (Rationale: In a digital rectal examination for BPH, the prostate is asymmetrical and enlarged; in prostate cancer, the exam shows nodules and a fixed position. PSA is specific to the prostate and is released by both benign and malignant cells; however, in BPH the amounts of the free form of PSA and complex PSA would be different. The other tests are not helpful in distinguishing cancer from BPH)

The nurse attends a conference meeting regarding crisis intervention. Which of the following statements by the nurse requires follow-up? a. "Crises are personal by nature. What may be considered a crisis situation by one individual may not be so for another.". b. "The development of a crisis situation follows a relatively unpredictable course." c. "Crises are acute and will be resolved within a brief period." d. "The therapist, or other intervener, becomes a part of the individual's life situation."

b. "The development of a crisis situation follows a relatively unpredictable course."

A nurse is volunteering at a health screening event sponsored by a local church and community center. The nurse is educating men about benign prostatic hyperplasia (BPH). Which of the following men is at greatest risk for developing BPH? a. A 27-year-old Hispanic man who has a family history of BPH b. A 56-year-old African American man who eats meat daily c. A 52-year-old Caucasian man who has a family history of BPH d. A 38-year-old Japanese man who is a vegetarian

b. AA eats meat Although the exact cause of BPH is unknown, risk factors include older age, family history, race (highest in African Americans and lowest in native Japanese), and a diet high in meat and fats.

Which of the following would the nurse evaluate as the best indicator of a positive outcome regarding kidney function for a client diagnosed with urinary calculi? a. Client temperature is only mildly elevated following passage of renal calculi. b. Client's BUN and creatinine are within normal limits. c. Client's electrolytes are within normal limits. d. Client's urine output is within normal range for age.

b. BUN Creatinine levels WNL

A nurse is providing instructions to a client who has a Rx for metronidazole (Flagyl) to treat peptic ulcer. The client asks the nurse why this medication has been Rx. Which of the following responses is correct? a. to get rid of the infection from giardiasis b. to get rid of the infection from H. pylori c. to increase the pH of gastric juices in the stomach d. to decrease the pH of gastric juices in the stomach.

b. H. pylori (gram - organism) that resides in the stomach and duodenum. This drug greatly reduces the recurrence of PUD.

A nurse in a provider's office is obtaining a history from a client who is being evaluated for benign prostatic hyperplasia. Which of the following findings are indicative of this condition? (select all) a. backache b. frequent UTIs c. weight loss d. hematuria e. urinary incontinence

b. UTI's: d/t urinary stasis d. hematuria e. incontinence: overflow d/t increase volume of residual urine a. backache: prostate CA c. wt. loss: prostate CA

The nurse caring for a client with uncomplicated cholelithiasis anticipates that the client's laboratory test results will show an elevation in: a. Serum amylase. b. Alkaline phosphatase. c. Indirect bilirubin. d. Mean corpuscular hemoglobin concentration (MCHC).

b. alkaline phosphatase Obstructive biliary disease causes an elevation of alkaline phosphatase. Direct bilirubin rises, not indirect. MCHC and serum amylase are unrelated to cholelithiasis.

In caring for a client 4 days after cholecystectomy, the nurse notices that the drainage from the T-tube is 600 mL in 24 hours. Which is the appropriate action by the nurse? a. Encourage an increased fluid intake. b. Assess drainage characteristics and notify the physician. c. Clamp the tube for 30 minutes every 2 hours. d. Place the client in supine position.

b. assess drainage characteristics/notify physician The T-tube may drain 500 mL in the first 24 hours and then decrease. The drainage for this client is too high, so the tube should not be clamped. Placing the client in a supine position is not helpful, nor is increasing fluid intake.

A nurse is completing d/c instructions with a client who has spontaneously passed a calcium oxalate stone. Which of the following foods should the nurse instruct the client to avoid? select all a. red meat b. black tea c. cheese d. whole grains e. spinach

b. black tea e. spinach

A nurse is providing d/c teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (select all) a. take baths rather than showers b. clamp t-tube for 1-2 hours before and after meals c. keep the drainage system above the level of the gallbladder d. expect to have constipation e. empty drainage bag every 8 hours

b. clamp t-tube 1-2 hours before and after meals to assess tolerance to food e. empty drainage bag every 8 hours a. soaking in water increases the risk of infection c. keep below the level of the gallbladder to decrease the chance of infection d. diarrhea is common, color will return within a week

A nurse is completing the admission assessment of a client who has a kidney stone. Which of the following is an expected finding? a. bradycardia b. diaphoresis c. nocturia d. bradypnea

b. diaphoresis a. tachy not bradycardia c. olig not nocturia d. tachy not bradypnea

Amanda's mobile home was destroyed by a tornado. Amanda received only minor injuries but is experiencing disabling anxiety in the aftermath of the event. The most appropriate crisis intervention with Amanda would be to a. encourage her to recognize how lucky she is to be alive. b. discuss stages of grief and feelings associated with each. c. identify community resources that can help Amanda. d. suggest that she find a place to live that provides a storm shelter.

b. discuss stages of grief and feelings associated with each.

A client with severe jaundice due to obstruction of the bile duct with stones is admitted to the hospital. The nurse encourages the client to ambulate in the halls to maintain muscle strength, but the client remains in the room. The nurse determines that the client's reluctance to leave the room is likely due to: a. Fatigue. b. Embarrassment about the jaundice. c. An attempt to prevent infection. d. Fear of strange surroundings.

b. embarrassment

The nurse is caring for a man who has returned to the unit from the recovery room following a transurethral resection of the prostate (TURP). His urinary drainage bag is filled with dark red fluid with obvious clots. He is having painful bladder spasms. What would the nurse do first? a. Assess his intake and output since surgery. b. Report the assessments to his urologist. c. Nothing, because these manifestations are expected following a TURP. d. Administer pain medication in the form of a B&O (belladonna and opiates) suppository.

b. report to the urologist The nurse should notify the surgeon. Dark red fluid with obvious clots and painful bladder spasms could indicate that the client may be hemorrhaging postoperatively; the doctor will need to know this to direct the next actions needed to keep the client safe. The other answers do not address the need for appropriate action.

A nurse is completing preoperative teaching for a client who will undergo a lap chole. Which of the following should be included in the teaching? a. the scope will be passed through your rectum b. you may have shoulder pain after surgery c. the t-tube will remain in place for 1-2 weeks d. you should limit how often you walk for 1-2 weeks

b. shoulder pain: due to the free air that is introduced into the abdomen during laparoscopic surgery

When conducting a health assessment, which of the following would most likely elicit information about sexual concerns? a. "Following your prostate surgery, when did you first notice you had problems with sexual intercourse?" b. "Tell me about your experience with sexual function since you developed prostate enlargement." c. "Do you miss having sex?" d. "Why do you think you should be sexually active at your age?"

b. tell me about your experience with sexual function This is stated in an appropriate way to allow the client to feel free to ask any question about his sexual concerns. The other answers presume problems or contain judgmental attitudes.

A client scheduled for a cholecystectomy is participating in a preoperative class. The nurse providing teaching would include which of the following as high-priority teaching for this client? (Select all that apply.) a. Understanding the procedure b. Turn, cough, and deep breathing c. Fluid and diet intake d. Early ambulation e. Leg exercises

b. turn, cough, deep breath d. early ambulation The highest priority for post-operative clients is the prevention of pneumonia. This surgery's location causes breathing to be shallow, and the client can be at risk for impaired breathing. Turn, cough, and deep breathing, along with early ambulation will assist the client to expand the lungs. Understanding the procedure is reinforced by the nurse, but is the responsibility of the surgeon. Leg exercises and fluid and diet are important but have a lower priority than the return of respiratory function.

The nurse is assessing a client who is suspected of experiencing an enlarging prostate gland (BPH). The nurse expects the enlarging prostate in BPH to be manifested by assessment of problems with which of the following? a. Peripheral vascular function b. Urinary elimination c. Bowel elimination d. Skin integrity

b. urinary elimination

A client with peptic ulcer disease (PUD) is scheduled for a vagotomy and asks the nurse why the procedure is being performed. The nurse tells the client: a. "A vagotomy causes the stomach to heal." b. "A vagotomy cuts the nerve that stimulates acid secretion." c. "A vagotomy decreases digestion of food." d. "A vagotomy decreases the body's reaction to stress."

b. vagus nerve stimulates acid recreation The vagus nerve stimulates the secretion of hydrochloric acid. Cutting the nerves decreases the production of acid in the stomach. The vagus nerve is not responsible for the reaction to stress, healing of the stomach, or the digestion of food.

After prostate surgery, what could be administered to relieve bladder spasms?

belladonna and opium suppositories

What would a high total bilirubin level indicate?

biliary obstruction (impaired excretion)

what are the 4 manifestations of hemorrhaging

blood in stool or vomit fatigue, weakness, dizziness orthostatic hypotension hypovolemic shock

A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. At the beginning of the client's hospitalization, the most important nursing action is to: a. severely restrict the client's physical activities. b. weigh the client daily, after the evening meal. c. monitor the client's vital signs, serum electrolyte levels, and acid-base balance. d. instruct the client to keep an accurate record of her food and fluid intake.

Brock Nichols, a 4-year-old preschooler, is being seen in the emergency department where you practice nursing. His mother reports that Brock has been vomiting for 3 days and is unable to "keep anything down." What poses the greatest danger to Brock? a. Nausea b. Anorexia c. Dehydration d. Choking on increased salivation

The nurse is assessing a client who is suspected of experiencing an enlarging prostate gland (BPH). The nurse expects the enlarging prostate in BPH to be manifested by which of the following symptoms? a Skin integrity b Peripheral vascular function c Urinary elimination d Bowel elimination

The UAP tells the nurse I think the client is confused. He keeps telling me he has to void, but that is not possible, he has a cath in place that is draining well. The nurse should tell the UAP: a. his cath is probably plugged. I will irrigate it b. That is a common problem after prostate surgery. The client only imagines the urge to void. c. The urge to void is usually created by the large catheter, and he may be having some bladder spasms. d. I think he may be somewhat confused.

c ( The indwelling cath creates the urge to void and can also cause bladder spasms. The nurse should ensure adequate bladder emptying by monitoring urine output and characteristics. Urine output should be at least 50 mL/hr A plugged cath, imagining the urge to void, and confusion are less likely reasons for the clients problem)

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should Nurse Anthony do first? A Increase the I.V. flow rate B Notify the physician immediately C Assess the irrigation catheter for patency and drainage D Administer meperidine (Demerol), 50 mg I.M., as prescribed

c (Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as meperidine, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication.)

A client who has a TURP has a 3 way indwelling cath. with continuous bladder irrigation. In which of the following circumstances should the nurse increase the flow rate of the irrigation? a. when the drainage is continuous but slow b. when drainage appears cloudy and dark yellow c. when drainage becomes bright red d. when there is no drainage of urine and irrigating solution

c (The decision by the surgeon to insert a cath after TURP depnds on the amount of bleeding that is expected. During irrigation after a TURP the rate at which the solution enters the bladder should be increased when the drainage become brighter red. The color indicates the presence of blood. Increasing the solution helps flush the cath well so that clots do not plug it)

A client with BPH has an elevated PSA level. The nurse should: a. instruct the client to request having a colonoscopy before coming to conclusions about the PSA result b. instruct the client that the urologist will monitor the PSA level bi-annually when elevated c. determine if the prostatic palpatation was done before or after the clients blood sample was drawn. d. ask the client if he emptied his bladder before the blood sample was obtained.

c (rectal and prostate exams can increase PSA levels. The prostatic palpitation should be done after the blood sample is drawn. The PSA level must be monitored more often than bi-annually if the level is elevated. A colonoscopy is not related to the findings. It is not necessary to void prior to having PSA blood levels drawn)

A client with peptic ulcer disease (PUD) suddenly complains of severe abdominal pain. The nurse should: (Select all that apply.) a. Obtain an order for narcotics. b, Administer the prescribed proton-pump inhibitor. c. Withhold oral food and fluids. d. Place the client in Fowler's position. e. Notify the physician.

c, d and e

The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client needs more education about the illness if she makes which comments? Select all that apply. a. "I know that this illness is chronic and intermittent. I will always have to control it." b. "If I start severely restricting my eating, I may be building up to a bingeing episode." c. "When I am not bingeing and purging, I can skip the eating disorder support group." d. "I have made a real effort to be more social and involved in activities." e. "My depression is gone so I do not need my antidepressant any longer."

c, e

Which of the following is a correct assumption regarding the concept of crisis? a. crises occur only in individuals with psychopathology. b. the stressful event that precipitates crisis is seldom identifiable. c. a crisis situation contains the potential for psychological growth or deterioration. d. crises are chronic situations that recur many times during an individuals's life.

c. a crisis situation contains the potential for psychological growth or deterioration.

A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings requires immediate intervention by the nurse? a. flank pain that radiates to the lower abdomen b. client report of nausea c. absent urine output for 2 hours d. client report of feeling sweaty

c. absent urine output for 2 hours (30mL/hr WNL) The others ARE findings of a renal calculus, but not the priority

A male client who presents to the emergency department with coffee-colored urine and edema states he had a bad sore throat a few weeks ago. HIs BP is elevated, and urinalysis shows blood and protein in the urine. The nurse interprets that this clinical picture is consistent with which developing health problem? a. UTI b. urinary calculi c. acute glomerulonephritis d. acute prostatitis

c. acute glomerulonephritis

The client with a history of recurrent urinary tract infections due to renal calculi is to undergo extra corpeal shock wave lithotripsy. Post procedure, the nurse will need to evaluate the client for: a increased urine output. b bleeding at the incision site. c bleeding. d incontinence.

c. bleeding

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following are expected findings? (select all) a. reports pain relived by eating b. reports pain occurs often at night c. reports a sensation of bloating d. reports pain occurs 1/2 to 1 hour after a meal e. reports pain upon palpation of the epigastric region

c. bloating d. pain 1/2 to 1 hour after a meal e. pain in epigastric region p palpation

The post-cholecystectomy client asks the nurse when the T-tube will be removed. The appropriate response from the nurse is: a. "The day after surgery." b. "When the tube stops draining." c. "When your stool turns brown." d. "When the staples are removed."

c. brown stool When stools turn a normal brown, the tube is clamped for 1-2 hours before and after meals in preparation for removal. If the client tolerates the clamping, then the tube is removed. The remaining options are not factors determining tube removal.

The nurse hangs a new 3000 mL bag of irrigating fluid for a postoperative client who has had a transurethral resection of the prostate and sets the irrigation rate based on: a. Client comfort. b. Size of the urinary drainage bag. c. Color of the client's urine. d. Milliliters to be administered per hour.

c. color of urine The irrigation fluid is set to infuse as rapidly as needed to dilute urine to a pale pink color in order to prevent the formation of clots that could occlude urine flow. Client comfort will improve with the proper rate because clots are flushed and spasms are reduced; however, this is not the criterion used to set the drip. Milliliters per hour and size of the drainage bag are not considerations used to determine the rate of the drip.

A nurse is completing d/c teaching for a client who has an infection due to Helicobacter pylori. Which of the following statements by the client indicates understanding of the teaching? a. I will continue my Rx for corticosteroids b. I will schedule a CT scan to monitor improvement c. I will take a combination of medications for treatment d. I will have my throat swabbed to recheck for this bacteria

c. combo of meds antibiotics and a histamine receptor antagonist a. steroid use is a contributing factor to an infection caused by H. pylori. b. EGD not CT d. gastric samples not a throat swab

A nurse is assessing laboratory values for a client who may have acute glomerulonephritis. Which of the following findings should the urge report to the provider? a. urine specific gravity of 1.022 b. BUN of 16 mg/dL c. creatinine clearance of 48 mL/min/m2 d. potassium level of 4.2 mEq/L

c. creatinine clearance 24 hr urine is not WNL, indicating possible renal failure

During the abdominal assessment of a male client, the nurse palpates a large round mass in the hypogastric region. Which of the following could explain what this nurse has palpated? a. The client has kidney stones. b. The client is constipated. c. The client has a distended or full bladder. d. The client has a tumor in his small intestines.

c. distended/full bladder

The nurse is caring for a child diagnosed with nephrotic syndrome. Which of the following is the most appropriate nursing diagnosis for the child? a. Activity Intolerance b. Risk for Loneliness c. Risk for Impaired Skin Integrity d. Ineffective Coping

c. edema causes skin breakdown

The nurse, assessing a client diagnosed with kidney stones, suspects the development of calculi may be related to: (Select all that apply). a The client's intake of 3 bananas daily. b The client's intake of large quantities of tomatoes. c Immobility and sedentary lifestyle. d The client's intake of a liter of milk every day. e Dehydration following recent gastroenteritis.

c. immobility/sedentary lifestyle d. L of milk qd e. dehydration

A nurse in a clinic is reviewing the lab reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? a. serum albumin 4.1 g/dL b. WBC 9,511 u/L c. direct bilirubin 2.1 mg/dL d. serum cholesterol 171 mg/dL

c. increased direct bilirubin in the client with cholelithiasis

A client was admitted to the hospital a day after cholelithiasis. Which of the following new findings would indicate to the nurse that the common bile duct is obstructed by a stone? a. Right upper quadrant pain b. Nausea c. Jaundice d. Elevated cholesterol level

c. jaundice Nausea and right quadrant pain occur in cystic duct disease, but obstruction of the common bile duct causes a backup of bile in the liver resulting in jaundice. Cholesterol levels are not increased.

The nurse is evaluating the effectiveness of the medical treatment of a client with BPH and determines it has been effective based on which of the following findings? a. The client reports he has remained active and plays golf once a week. b. The client has been able to maintain sexual function since beginning treatment. c. The client has had no urinary tract infections since beginning treatment. d. The client reports his urine is clear dark amber in color.

c. no UTI The goal of medical treatment is to promote urine flow to prevent complications such as urinary tract infections, hydronephrosis, or other results of obstructed urine flow, so lack of urinary tract infections would be a positive outcome indicating the treatment is working. While sexual function is of concern to the medical team, sexual performance is not the goal of treatment. Physiological needs always are the priority. Clear dark amber color is abnormal; the color should be clear and light yellow. BPH does not affect activity or golf.

A client is being evaluated for a possible duodenal ulcer. The nurse monitors the client for which of the following manifestations that would indicate this diagnosis? a. Distended abdomen b. Positive fluid wave c. Epigastric pain relieved by food d. History of chronic aspirin use

c. pain/food The pain of a duodenal ulcer is relieved by eating because the pancreatic juices stimulated by eating are high in bicarbonate. Aspirin use is irritating to the stomach. Distended abdomen and positive fluid wave are unrelated to ulcers.

A client with peptic ulcer disease (PUD) is scheduled for a pyloroplasty and asks the nurse about the procedure. The nurse tells the client which of the following? a. The vagus nerve is cut to reduce irritation. b. The distal portion of the stomach is removed. c. The pylorus is cut to relax the muscle and enlarge the opening. d. The ulcer and tissue producing hydrochloric acid are removed.

c. pylorus is cut Cutting the muscle and enlarging the opening is a pyloroplasty. When the vagus nerve is cut, it is a vagotomy. Removing a portion of the stomach is a subtotal gastrectomy. Cutting the ulcer and surrounding tissue is a Billroth II procedure.

The nurse is caring for a client who was admitted to the hospital with peptic ulcer disease (PUD). Which of the following, if noted by the nurse, is a manifestation of complications from PUD? a. Numbness in the legs b. Bradycardia c. A rigid, board-like abdomen d. Nausea and vomiting

c. rigid, board-like abdomen A risk of peptic ulcer disease is perforation, a surgical emergency. The nurse assesses the client with PUD for this possibility. The client will also have sudden sharp pain, possible nausea and vomiting, and tachycardia. Numbness in the legs is unrelated to perforation.

The nurse evaluates teaching of a client with glomerulonephritis as effective when the client: a. States the need to remain on bed rest until the urine is clear yellow. b. Demonstrates the care for the vascular shunt or peritoneal catheter. c. Chooses soy or animal proteins for allowed grams of protein in the diet. d. Limits fluid intake to 1500 mL per day.

c. soy or animal proteins Soy and/or animal protein are complete proteins that are necessary for growth and tissue healing. Complete proteins are preferred, and this client's proteins are restricted. Bed rest is necessary during the acute phase of the disease only. Dialysis is not indicated for the client with glomerulonephritis. Sodium may be restricted if the client is edematous, but fluid intake is based on the client's fluid volume status.

A client taking sucralfate (Carafate) PO for PUD has been started on phenytoin (Dilantin) to control seizures. Which of the following should be included in the client's teaching? a. take both of these medications at the same time b. take sucralfate with a class of milk c. allow a 2 hour interval between these medications d. chew the sucralfate thoroughly before swallowing

c. sucralfate can interfere with the absorption of phenytoin

Andrew, a New York City firefighter, and his entire unit responded to the terrorist attacks at the World Trade Center. Working as a team, he and his best friend, Carlo, entered the area together. Carlo was killed when the building collapsed. Andrew was injured but survived. Since that time, Andrew has had frequent nightmares and anxiety attacks. He says to the mental health worker, "I don't know why Carlo had to die and I didn't!" This statement by Andrew suggests that he is experiencing a. spiritual distress. b. night terrors. c. survivor's guilt. d. suicidal ideation.

c. survivor's guilt.

Which of the following is the desired outcome of working with an individual who has witnessed a traumatic event and is now experiencing panic anxiety? a. the individual will experience no anxiety b. the individual will demonstrate hope for the future. c. the individual will identify that anxiety is at a manageable level. d. the individual will verbalize acceptance of self as worthy.

c. the individual will identify that anxiety is at a manageable level.

A nurse is presenting information to a client who has a new diagnosis of chronic glomerulonephritis. Which of the following nursing statements is appropriate? a. a high sodium diet is recommended b. the destruction of the glomeruli occurs rapidly c. the cause of the disease is not known d. to compensate, the number of functioning nephrons is increased

c. the kidney atrophies, and tissue is not available for biopsy and diagnosis. a. low sodium b. gradual destruction d. number decreases

The nurse identifies which of the following nursing diagnoses as highest priority for the client with peptic ulcer disease (PUD)? a. Acute Pain b. Ineffective Health Maintenance c. Impaired Tissue Integrity: Gastrointestinal d. Nausea

c. tissue integrity PUD is an interruption of the integrity of the gastric lining. While the other nursing diagnoses will be present and need to be addressed at some point, disruption of the integrity of the lining of the stomach is the highest because of the risk for perforation.

What are the 3 complications of cholelithiasis

cholecystitis common bile duct obstruction with possible jaundice and liver damage common duct obstruction with pancreatitis

Formation of stones in the gallbladder

cholelithiasis

What are gallstones comprised of

cholesterol

What 6 diseases/conditions are risk factors for gallbladder disease?

cirrhosis sickle cell anemia leukemia hyperlipidemia ileal disease or resection glucose intolerance

Other than a DRE and PSA test, what (3) other diagnostic tests would you expect for a patient with BPH?

cystoscopy to r/o bladder issues U/A to r/o infection flow, pressure, and residual studies

A client with anorexia nervosa tells a nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to promote the client's receptivity to treatment? a. Avoid discussing the client's distorted perceptions and feelings. d. Focus discussions on food, body weight, and body image. c. Discussing unrealistic cultural standards regarding weight. d. Provide objective data and feedback regarding the client's weight

A hospitalized client who refuses to eat because she fears that the kitchen personnel are poisoning her food is experiencing A. Hallucinations B. Anorexia C. Agoraphobia D. Delusions

When conducting a health assessment on a person with Benign Prostatic Hyperplasia, which statement would most likely elicit information about sexual concerns? a "Why do you think you should be sexually active at your age?" b "Following your prostate surgery, when did you first notice you had problems with sexual intercourse?" c "Do you miss having sex?" d "Tell me about your experience with sexual function since you developed prostate enlargement."

d ( Feedback Rationale: This is stated in an appropriate way to allow the client to feel free to ask any questions about his sexual concerns. The other answers presume problems or contain judgmental attitudes.)

The client who has a cold is seen in the emergency room with inability to void. Because the client has a history of BPH, the nurse determines that the client should be questioned about the use of which of the following medications? A Diuretics B Antibiotics C Antitussives D Decongestants

d (In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention can also be precipitated by other factors, such as alcoholic beverages, infection, bedrest, and becoming chilled.)

An older adult client is admitted for a transurethral resection of the prostate (TURP) to treat benign prostatic hyperplasia (BPH). Which item in the client's health history placed him at risk for developing BPH? a More than one sexual partner b Smoking history c Sedentary lifestyle d Age

d (Rationale Age is the most common risk factor for BPH. Almost all men will develop BPH if they live long enough. There may be a racial component as well, because Black and Hispanic men develop BPH earlier than White men, but Asian men develop it later. Smoking, sexual history, and a sedentary lifestyle are not risk factors for developing BPH.)

A nurse is volunteering at a health screening event sponsored by a local church and community center. The nurse is educating men about benign prostatic hyperplasia (BPH). Which male would be at greatest risk for developing BPH? a A 27-year-old Hispanic man who has a family history of BPH b A 38-year-old Japanese man who is a vegetarian c A 52-year-old Caucasian man who has a family history of BPH d A 56-year-old African American man who eats meat daily

d (Rationale: Although the exact cause of BPH is unknown, risk factors include older age, family history, race (highest in African Americans and lowest in native Japanese), and a diet high in meat and fats. )

A man whose BPH has been successfully managed through medical treatment visits the provider's office and reports he has suddenly had a return of symptoms including frequency, urgency, and a sensation of incomplete emptying after voiding. The nurse collects a thorough history and suspects the possible cause of the sudden exacerbation of the client's symptoms may be: a antihypertensive medications he was recently prescribed. b increased sexual activity since his wife has retired. c increased levels of exercise as he trains for a marathon. d over-the-counter medications he's been taking to treat cold symptoms.

d (Rationale: Over-the-counter medications, such as antihistamines and decongestants, can exacerbate the symptoms of BPH because they contain alpha adrenergic agents or have anticholinergic effects. Antihypertensives do not affect BPH. Increased sexual activity and exercise will not aggravate symptoms of BPH.)

The nurse hangs a new 3000 mL bag of irrigating fluid for a postoperative client who has had a transurethral resection of the prostate. Which factor influences the proper irrigation rate? a Milliliters to be administered per hour b Size of the urinary drainage bag c Client comfort d Color of the client's urine

d (Rationale: The irrigation fluid is set to infuse as rapidly as needed to dilute urine to a pale pink color in order to prevent the formation of clots that could occlude urine flow. Client comfort will improve with the proper rate because clots are flushed and spasms are reduced; however, this is not the criterion used to set the drip. Milliliters per hour and size of the drainage bag are not considerations used to determine the rate of the drip.)

A nurse is caring for a client who has a new diagnoses of BPH. The nurse should anticipate a prescription for which of the following medications? A oxybutynin b. diphenhydramine c. ipratropium d. tamsulosin

d (Tamsulosin is an alpha-adrenergic receptor antagonist that relaxes the bladder outlet and the prostate gland which improves urinary flow. a: is an anticholinergic that treats overactive bladder. CONTRAINDICATED. Causes urinary retention. The others are not urinary meds)

A man whose BPH has been successfully managed through medical treatment visits the provider's office and reports he has suddenly had a return of symptoms including frequency, urgency, and a sensation of incomplete emptying after voiding. The nurse collects a thorough history and suspects the possible cause of the sudden exacerbation of the client's symptoms may be: a. Increased sexual activity since his wife has retired. b. Increased levels of exercise as he trains for a marathon. c. Antihypertensive medications he was recently prescribed. d. Over-the-counter medications he's been taking to treat cold symptoms.

d. OTC cold meds Over-the-counter medications such as antihistamines and decongestants can exacerbate the symptoms of BPH because they contain alpha adrenergic agents or have anticholinergic effects. Antihypertensives do not affect BPH. Increased sexual activity and exercise will not aggravate symptoms of BPH.

The client is experiencing urolithiasis composed of Struvite. The nurse would teach the client that the cause of these stones is: a calcium. b uric acid. c cystine. d bacteria.

d. bacteria

What race/ethnicity is more prone to gallbladder disease

native americans hispanics

Marie, age 56, is the mother of five children. Her youngest child, who had been living at home and attending the local college, recently graduated and accepted a job in another state. Marie has never worked outside the home and has devoted her life to satisfying the needs of her husband and children. Since the departure of her last child from home, Marie has become increasingly dependent. Her husband is very concerned and takes her to the local mental health center. The most appropriate nursing intervention with Marie would be to a. refer her to her family physician for a complete physical examination b. suggest she seek outside employment now that her children have left home.. c. identify convenient support systems for times when she is feeling particularly despondent. d. begin grief work and assist her to recognize areas of self-worth separate and apart from her children.

d. begin grief work and assist her to recognize areas of self-worth separate and apart from her children.

A client is to undergo a cholecystography. The nurse instructs the client that the night before the test, the client should plan a meal that is: a. Full liquid. b. Low in protein. c. High in carbohydrates. d. Fat-free.

d. fat-free A fat-free diet is ordered the night before the test because fat will cause the gallbladder to contract, and a fat-free diet allows for the accumulation of the contrast media in the gallbladder. The client may have carbohydrates, protein, and liquids as long as there is no fat.

A nurse is reviewing a new Rx for ursodiol (Ursodeoxycholic Acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? a. reduces bilary spasms b. reduces inflammation in the biliary tract c. dilates the bile duct to promote passage of bile d. dissolves gall stones

d. gradually dissolves gall stones (could take 2 years)

The nurse is caring for a child diagnosed with glomerulonephritis. Which of the following findings will the nurse expect in this client? a. A urine specific gravity of 1.000 b. Low blood urea nitrogen (BUN) level c. Hypotension d. Red-brown urine

d. gross hematuria elevated specific gravity elevated BP elevated BUN

A nurse is providing teaching for a client who has a new dx of dumping syndrome following gastric surgery. Which of the following should be included in the teaching? a. eat 3 moderate-sized meals a day b. drink at least one glass of water with each meal c. eat a bedtime snack that contains a milk product d. increase protein in the diet

d. high protein, high fat, low fiber, and moderate to low carbohydrate diet a. small, frequent meals b. eliminate liquids with meals (as well as 1 hr before and 1 hr after) c. avoid milk products

A client has been diagnosed with renal obstruction due to calculi. The nurse should evaluate the client for the complication of: a Congestive heart failure. b hypokalemia. c hypophospholemia. d hydronephosis.

d. hydronephosis

Recognizing the risk for urolithiasis in the immobilized client, the nurse appropriately plans to: a. Administer a calcium supplement. b. Maintain an indwelling urinary catheter. c. Regularly monitor urine pH. d. Increase fluid intake to 3000 mL per day.

d. increase fluids

Ginger, age 19 and an only child, left 3 months ago to attend a college of her choice 500 miles away from her parents. It is Ginger's first time away from home. She has difficulty making decisions and will not undertake anything new without first consulting her mother. They talk on the phone almost every day. Ginger has recently started having anxiety attacks. She consults the nurse practitioner in the student health center. What is this type of crisis called? a. crisis resulting from traumatic stress b. dispositional crisis. c. psychiatric emergency. d. maturational or developmental crisis.

d. maturational or developmental crisis.

A nurse is providing a client who has peptic ulcer disease with instructions about managing his condition. Which of the following instructions should the nurse include? (select all) a. eat six small meals a day b. drink milk to aid in healing your ulcer c. low-dose ASA should be avoided d. seek measures to reduce stress e. avoid smoking

d. reduce stress e. avoid smoking a. eating 6 meals a day may stimulate production of gastric acid b. avoid milk/cream it stimulates production of gastric acid c. low-dose ASA therapy is permitted

A nurse is caring for a client who has a new dx of BPH. The nurse should anticipate a Rx for which of the following medications? a. oxybutynin (Ditropan) b. diphenhydramine (Benadryl) c. ipratropium (Atrovent) d. tamsulosin (Flomax)

d. tamsulosin is an alpha-adrenergic receptor antagonist that relaxes the bladder outlet and the prostate gland, which improves urinary flow.

A client has been diagnosed with a kidney stone, lodged within the medulla of the right kidney. Which of the following will this stone most affect? a. The filtration of blood b. The clearance of toxins c. The removal of lymph d. The collection of urine

d. the collection of urine

A nurse is completing teaching for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which of the following statements made by the client indicates understanding of the teaching? a. I will be fully awake during the procedure b. Lithotripsy will reduce my chances of having stones in the future c. I will report any bruising that occurs to my doctor d. Straining my urine following the procedure is important

d. to verify that the stone has passed a. patient receives conscious sedation b. procedure breaks the stones up c. brushing is expected after procedure

collection of infected fluid in the gallbladder

empyema

What would a high direct bilirubin level indicate?

excretion is impaired by obstruction in the liver

Other than H. pylori infections and NSAID use, what are 3 risk factors for peptic ulcer disease?

family history smoking advanced age

What are the 5 complications of cholecystitis

gangrene and perforation with peritonitis chronic cholecystitis empyema fistula formation gallstone ileus

What is the classic symptom of peptic ulcer disease?

gnawing, burning, aching, hunger like epigastric pain that can radiate to the back that is relieved by eating

What are the 3 complications of PUD?

hemorrhage obstruction perforation

What is the patient at most risk for after BPH surgery? (3)

infection bladder spasms bleeding

How do the alpha reductase inhibitors work?

inhibits the conversion of testosterone to DHT and cause the prostate to shrink

how and uric acid stones be prevented

limiting animal product intake

What sex is most affected by kidney stones

males

In a DRE, what would be indicative of tenderness?

prostatitis

What four common medications can worsen symptoms of BPH and should be avoided by all older men?

pseudoephedrine - restricts urine flow antihistamines TCAs testosterone/anabolic steroids - enlarges prostate

How can calcium stones be prevented

reducing sodium and animal product intake

How do the alpha adrenergic blockers work?

relax the smooth muscle of the prostate and bladder neck to relive obstruction

What would a high indirect bilirubin level indicate?

rise in RBC hemolysis (sickle cell or transfusion reaction)

What are the 4 manifestations of an obstruction

sensation of epigastric fullness nausea/vomiting electrolyte imbalances metabolic alkalosis

What are the 7 manifestations of a perforation

severe upper abdominal pain radiating into the shoulder RIGID BOARDLIKE ABDOMEN absence of bowel sounds diaphoresis tachycardia rapid shallow respirations fever

What are the three adverse effects of alpha reductase inhibitors?

sexual dysfunction decreased libido decreased ejaculate volume

Regionaly where is the highest incidence of kidney stones

south and midwestern US

Why would CBI (continuous bladder irritation) be ordered after surgery?

to prevent formation of blood clots, which can obstruct urinary output

What are the three types of bilirubin lab tests?

total direct (conjugated) indirect (unconjugated)

What age group is most affected by kidney stones

young/middle adults

The nurse is screening a client for the risk of nephritis. Which question should the nurse ask? (Select all that apply.) "Do you have a history of diabetes?" "Does your family have a history of kidney disease?" "Do you have a history of low blood pressure?" "Do you have a history of bladder infections?" "Does your family have a history of gastric reflux?

"Do you have a history of diabetes?" "Does your family have a history of kidney disease?" "Do you have a history of bladder infections?" Diabetes and hypertension (not low blood pressure) can cause damage to the fragile vessels of the nephron, thereby putting the client at greater risk for nephritis. A family history of kidney disease also predisposes the client to developing nephritis. Infections can travel from the bladder to the kidney, thereby damaging the kidney. Gastric reflux is not related to nephritis.

The family of a teen with anorexia nervosa is discussing treatment options with the nurse. They would like to find an inpatient program to treat their child, who has a BMI of 17 kg/m2. How should the nurse respond? "An inpatient stay would be a good idea if you can afford it as they have the highest success rates." "At this point, family and group therapy would be a better option than an inpatient program." "What would your child rather do? If the client isn't interested in an inpatient program, it probably won't be effective." "Initially, it is best to start with a structured day treatment program rather than an inpatient stay."

"Initially, it is best to start with a structured day treatment program rather than an inpatient stay." Day treatment programs are considered the first-line treatment approach, so the nurse would indicate that this would be the best way to begin treatment, especially since the client has mild anorexia as indicated by the BMI. Family and group therapy will not provide the more intensive structure of a day program. An inpatient program is the next line of treatment if a day treatment program does not produce the desired outcome and the client continues to lose weight.

The nurse plans care for a client being treated for an eating disorder. Which question should the nurse ask to encourage the client to re-experience positive emotions? "Can you describe things that trigger eating disordered behaviors for you?" "What kinds of things did you enjoy doing before the eating disorder took over?" "Do you use alcohol to help deal with the feelings and emotions you're experiencing?" "Do you feel that the environment you live and work in contributes to high amounts of stress for you?"

"What kinds of things did you enjoy doing before the eating disorder took over?" Encouraging clients to reconnect with activities and experiences that they previously enjoyed can help them begin to regain control over their own behaviors and re-experience positive emotions. Questions about triggers, alcohol use, and environmental stressors are also important but would not directly elicit information to support development of an intervention to promote re-experiencing of positive emotions.

The nurse is providing a teaching session to care providers concerning the identification of eating disorders (EDs) in the pediatric population. Which statement would help pediatric care providers identify EDs in younger clients? "Unwillingness to try new foods is an early indication of EDs in young clients." "EDs in younger clients are often associated with anxiety disorders." "EDs are less likely in younger clients with a history of obesity." "Younger clients with EDs tend to be boys."

"Younger clients with EDs tend to be boys." EDs in younger clients are underdiagnosed by pediatric care providers. The rate of EDs in younger clients is higher in boys than in girls; the male/female ratio is 6:1. EDs are more, not less, likely in younger clients with a history of obesity. EDs in adolescents are often associated with anxiety disorders. Unwillingness to try new foods is characteristic of a picky eater; while a child with an ED may have some picky-eating behaviors, the primary criterion is inadequate (restrictive) intake, manifested by a disinterest in food; the intake does not support the child's nutritional or energy needs.

The client diagnosed with nephritis states, "No one in my family has ever had any kidney disease. Where do you think this nephritis came from?" Which response by the nurse is most accurate? "I think your celiac disease must have damaged your kidneys." "The fact that you have thyroid disease probably caused damage to your kidneys." "It is possible that your history of arthritis caused the nephritis." "Your congestive heart failure might have damaged your kidneys."

"Your congestive heart failure might have damaged your kidneys." While the cause of nephritis is unknown, many diseases can damage the kidneys and cause nephritis. Congestive heart failure is one of them due to poor perfusion to the kidneys. Thyroid disease, celiac disease, and arthritis do not.

The community health nurse speaks with a group of older adult community members about reasons they are at a higher risk for nephritis. Which reason should the nurse include? Higher incidence of cardiac problems Lower risk of developing chronic kidney disease Long-term use of proton pump inhibitors (PPIs) Long-term use of antihypertensives

Long-term use of proton pump inhibitors (PPIs) Medications such as PPIs and certain antibiotics (not antihypertensives) are associated with an increase in nephritis. Older adults have a higher risk of developing chronic kidney disease. Cardiac problems are not shown to increase the risk of nephritis.

The nurse is caring for a client with suspected acute glomerulonephritis. Which clinical manifestation supports this suspicion? (Select all that apply.) Tea-colored urine Microscopic hematuria Weight loss Crackles auscultated in lungs Low blood pressure

Tea-colored urine Microscopic hematuria Crackles auscultated in lungs Manifestations of acute glomerulonephritis include crackles in the lungs, tea-colored urine, microscopic hematuria, high blood pressure, and weight gain.

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