306 Exam 4 Quizzes
When assessing the surgical history of a male-to-female (MTF) patient, which information would the nurse inquire about? SATA. a. Penectomy b. Phalloplasty c. Vaginoplasty d. Hysterectomy e. Breast surgery f. Prostate problems
a, c, e, f
Which molecule excessively accumulated in the blood to precipitate the signs and symptoms associated with a diabetic coma? a. Sodium bicarbonate, causing alkalosis b. Ketones as a result of rapid fat breakdown, causing acidosis c. Nitrogen from protein, causing ammonia intoxication d. Glucose from rapid carbohydrate metabolism, causing drowsiness
b
Which skin assessment provides the best determination of adequate hydration and nutrition in a child? a. Color b. Turgor c. Texture d. Temperature
b
Which requirement would a nurse have for the 12 mo before a vaginoplasty or a phalloplasty? a. Hormone therapy b. Monthly vocal coaching c. Biweekly therapy sessions with a licensed psychotherapist d. Continuously living in the role of the desired gender identity
d
Which client is at risk for developing type 2 diabetes mellitus? SATA. a. 15-year-old male who plays video games 6h per day b. 36-year-old female with a h/o gestational diabetes c. 47-year-old male who weight s 250 lbs. and is 5'9" tall d. 28-year-old female with polycystic ovarian syndrome (POS) e. 60-year-old male of Native American descent who abuses alcohol
ALL
Which finding would lead the nurse to recheck the blood glucose level of a diabetic client before administering a mealtime insulin dose? SATA. a. Confusion b. Drowsiness c. Diaphoresis d. Nervousness e. Heart rate 110 beats/min
ALL
Which physiological changes would the nurse expect to find in a client with a 20-year history of type 2 diabetes? a. Blurry, spotty, or hazy vision b. Arthritic changes in the hands c. Hyperactive knee and ankle jerk reflexes d. Dependent pallor of the feet and lower legs
a
A client with type 1 diabetes has a above-the-knee amputation because of severe lower extremity arterial disease. Two days after surgery, which interventions is appropriate when preparing the client to eat dinner? a. Checking the client's serum glucose level b. Assisting the client out of bed into a chair c. Placing the client in the high-fowler position d. Ensuring the client's residual limb is elevated
a
An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus? a. Ketones b. Glucose c. Lactic acid d. Glutamic acid Which molecule excessively
a
The nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications? SATA. a. Examine the feet daily b. Wear well-fitting shoes c. Perform regular exercise d. Powder the feet after showering e. Visit the primary HCP weekly f. Test bathwater with the toes before bathing
a, b, c
The nurse is assessing a child with delayed growth. Which questions does the nurse include in the assessment while interviewing the parents? SATA. a. Tell me about diseases in your family b. What kind of medications does the child take c. Have there been changes in the child's appetite d. What kind of developmental issues did the child have e. What behavioral therapies is the child undergoing now
a, b, c, d
What are the signs and symptoms of DKA? SATA. a. Ketonuria b. Ketonemia c. Dehydration d. Acetone breath e. Shallow, slow breathing
a, b, c, d
Which conditions or procedures are most likely to increase fluid requirements for children? SATA. a. Fever b. Burns c. Shock d. Vomiting excessively e. Mechanical ventilation f. CHF
a, b, c, d
Which disease processes increase body requirements for fluid? SATA. a. Burns b. Shock c. Diabetes insipidus d. DKA e. SIADH
a, b, c, d
A client with type 1 diabetes for 25 years states, "I have been really bad for the past 15 years. I have not paid attention to my diet and have done little to control my diabetes." Which common complications of diabetes might the nurse expect to identify when assessing this client? SATA. a. Leg ulcers b. Loss of visual acuity c. Thick, yellow toenails d. Increased growth of body hair e. Decreased sensation in the feet
a, b, c, e
Which factors determine the fluid requirements of an infant? SATA. a. Size b. Hydration status c. Underlying disease d. Immunization status e. Environmental factors
a, b, c, e
UA of a patient with type 1 DM shows ketones, glucose, and high concentrations of H+ ions. On examination the nurse finds that the patient's skin is dry, the radial artery pulse is weak, and the LOC is decreased. The nurse alerts the provider and prepares to perform which interventions? SATA. a. Administer insulin b. Administer intravenous fluids c. Administer furosemide d. Administer amitriptyline e. Administer potassium supplements
a, b, e
Which manifestations would the nurse include when teaching a client about ketoacidosis? SATA. a. Confusion b. Hyperactivity c. Excessive thirst d. Fruity-scented breath Decreased urinary output
a, c, d
About which potential complication would the nurse inform the patient who is having a phalloplasty? SATA. a. Penile necrosis b. Prostate cancer c. Urinary tract stenosis d. Donor graft scarring e. Dissatisfaction with results
a, c, d, e
What are extracellular fluid components? SATA. a. Plural fluid b. Cellular fluid c. Blood vessels d. Synovial fluid e. Interstitial fluid f. Cerebrospinal fluid
a, c, d, e, f
The mother of a child with type 1 DM asks why her child cannot avoid all those "shots" and instead take pills as an uncle does. What is the most appropriate response by the nurse? a. The pills only work with an adult pancreas b. The drugs affect fat and protein metabolism, not sugar c. Your child needs to have insulin replaced, and the oral hypoglycemics only add to an existing supply of insulin d. Perhaps when your child is older the pancreas will produce its own insulin, and then your child can take oral hypoglycemics
c
The nurse includes which education related to inflammation when providing discharge teaching for a patient after a modified radical mastectomy? a. A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week b. Do not allow anyone to take you BP or draw blood on the side where you had your breast removed c. Report any increased redness, swelling, warmth, or pain to your HCP d. Avoid the prone and hunchback positions, and ask your HCP about other activity restrictions
c
Which assessment finding indicates a need to activate the rapid response team when the nurse is caring for a diabetic client with a bacterial infection of the foot? a. Hypertonic bowel sounds in all 4 quadrants b. Blood glucose level 145 mg/dL c. Client report of level 9 pain of the foot (0 to 10 scale) d. Systolic blood pressure persistently 85 to 90 mmHg
d
Which clinical manifestations are appropriate when diagnosing nephrotic syndrome? a. Uric acid, edema, hypolipidemia b. Creatinine, edema, proteinuria, hyperalbuminemia c. Blood urea nitrogen, proteinuria, hypoalbuminemia d. Proteinuria, edema, hyperlipidemia, hypoalbuminemia
d
Which nursing measures are appropriate when encouraging the dehydrated child to drink fluids? SATA. a. Give carbonated drinks if the child prefers b. Force fluids with a syringe in the child's mouth c. Persuade the child to have fluids even if sleeping d. Use play techniques to have the child drink fluids e. Give flavored ice pops to provide necessary fluids
a, d, e
Which interpretation of skin turgor is accurate when the tissue remains suspended, or tented, for a few seconds and then slowly falls back on the abdomen? a. Proper hydration b. Poor skin turgor c. Normal tissue elasticity d. The assessment is done incorrectly
b
Which clinical manifestations in children help to distinguish between hypoglycemia and hyperglycemia? SATA. a. A child with hypoglycemia has sweating b. A child with hypoglycemia has nausea and vomiting c. A child with hyperglycemia has exaggerated reflexes d. A child with hyperglycemia has deep, rapid breathing e. A child with hyperglycemia has tachycardia and palpitations
a, d
A male-to-female patient and her partner come to the postoperative appointment. "My partner has some questions. He wants to know about my new vagina. What will it be made of?" Which response is best? a. The neovagina is made from silicone b. It is made with inverted penile tissue c. It will be made from parts of the scrotum d. The surgeon uses skin grafts to create the neovagina
b
Which are clinical manifestations of juvenile hypothyroidism? a. Sleepiness, dry skin, diarrhea b. Dry skin, sparse hair, slowed growth c. Diarrhea, dry skin, decelerated growth d. Constipation, dry skin, enlarged thyroid
b
Which are the cardinal signs of diabetes insipidus? a. Vascular anomalies b. Polyuria and polydipsia c. Hypotension and dehydration d. Dehydration and diminished urine output
b
Which common cause of DKA would the nurse consider when caring for a postoperative client with diabetes? a. Emotional stress b. Presence of infection c. Increased insulin dose d. Inadequate food intake
b
Which condition is appropriate for an 8 yo girl with dehydration who has demonstrated diminished urine output and lethargy since shortly after undergoing surgery? a. Wilms tumor b. Acute kidney injury c. Acute glomerulonephritis d. Hemolytic uremic syndrome
b
Which clinical manifestation is appropriate when assessing a child for possible nephrotic syndrome? a. Cola- or tea-colored urine b. Excessive loss of body weight c. Appearance of white lines on the nails d. Swelling of the genitalia in the morning
c
Which complication would the nurse assess for during transition period for a newborn born to a diabetic mother? a. Hypoglycemia b. Hyperglycemia c. Meconium stools d. Congenital hyperinsulinism
a
Which lab value supports the presence of DKA? a. Increased serum lipids b. Decreased hematocrit level c. Increased serum calcium levels d. Decreased blood urea nitrogen level
a
Which factor would the nurse take into account before selecting an insertion site for a short peripheral venous catheter? SATA. a. Type of therapy b. Length of therapy c. History of mastectomy d. Presence of dialysis fistula e. Axillary lymph node dissection
a, c, d, e
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. Which instruction would the nurse include in the teaching plan? SATA. a. The client should obtain a finger stick blood glucose reading before each meal b. The client does not need to follow a specific diet until insulin is required c. The teaching plan should include signs and symptoms of hypoglycemia d. The teaching plan should include how to administer regular insulin e. The teaching plan should include sick day rules
a, c, e
An adolescent patient reports constipation, weight gain, and depressed mood. The patient also feels cold in warm weather. The nurse has noticed a pattern of similar symptoms in adolescents in the area. Which does the nurse tell the patient to include in the diet? a. Iodized salt b. Iron-fortified milk c. Essential fatty acids d. Essential amino acids
a
Which option for prevention and early detection of breast cancer is the treatment of choice for a patient with a high genetic risk? a. Prophylactic mastectomy b. Breast self-exam (BSE) beginning at 20 yo c. Hormone-replacement therapy (HRT) combining estrogen and progesterone d. MRI and mammography every year beginning at age 30
d
Which patient complaint during assessment will support documentation by the nurse of a cystocele? a. Constipation b. Fecal impaction c. Feelings of vaginal fullness d. Difficulty emptying the bladder
d
A child with diabetes insipidus is admitted to the hospital. Which nursing interventions are most important for this child? SATA. a. Monitor temperature b. Check airway and breathing c. Monitor blood glucose levels d. Administer intravenous fluids e. Monitor urine volumes regularly
d, e
Which method is appropriate when assessing for fluid retention in a child with nephrotic syndrome who is not potty trained? a. Weigh the child daily b. Test the urine for hematuria c. Count the child's wet diapers d. Measure the abdominal girth weekly
a
Which goals are most associated with a positive outcome for a 6-mo child with volume excess? SATA. a. Flat fontanel b. SOB c. Minimal to no weight gain d. Output greater than input e. Balanced input and output
a, c, e
Which instructions does the nurse provide to a patient who is being discharged from an outpatient (same day) surgery unit after a modified radical mastectomy? a. Lie flat in the supine position b. Elevate the affected arm on a pillow c. Keep the affects arm flexed while walking d. Start ambulating and exercising this evening
b
Which statement about phalloplasty is accurate? a. Phalloplasty can be done laparoscopically b. Phalloplasty is performed in several stages c. A common complication of phalloplasty is rectovaginal fistula d. Phalloplasty is a common genital surgery with few complications
b
Which statement made by a diabetic client shows that dietary teaching by the nurse was effective? a. My diet should be rigidly controlled to avoid emergencies b. My diet can be planned around a wide variety of commonly used foods c. My diet is based on nutritional requirements that are the same for all people d. My diet must not include eating any combination dishes and processed foods
b
Which statement made by the patient indicates understanding of an appropriate nonsurgical method of treatment for pelvic organ prolapse? SATA. a. I should avoid using laxatives b. Kegel exercises should be performed to improve pelvic support c. I could use pessaries, or spheres, in my vagina d. Bladder training would be beneficial e. Oral hormone replacement therapy is an appropriate treatment
b, c, d
Which clinical manifestation will support the nurse documenting a cystocele in a patient? a. Constipation b. Bleeding from rectum c. Urine loss when laughing d. ARDS
c
Which clinical manifestations are appropriate with the diagnosis of acute poststreptococcal glomerulonephritis? a. Edema, increased urine volume, hypotension b. Edema, decreased urine volume, hypotension c. Edema, decreased urine volume, hypertension d. Edema, increased urine volume, hypertension
c
Which eye problem is the leading cause of blindness in clients with diabetes? a. Cataracts b. Glaucoma c. Retinopathy d. Astigmatism
c
Which first sign of improvement is appropriate to watch for while caring for a child with acute glomerulonephritis? a. Decrease in edema b. Increase in body weight c. Increase in urinary output d. Decrease in BP
c
Which is the most effective treatment options for children with type 1 diabetes? a. Diet only b. Oral agents c. Insulin and diet d. Diet and oral agents
c
Which is the priority short-term goal when teaching a client with type 1 diabetes who is placed on an insulin pump to control the diabetes? a. The client will adhere to the medical regimen b. The client will remain normoglycemic for 3 weeks c. The client will demonstrate correct use of the insulin pump d. The client will list three self-care activities that are necessary to control the diabetes
c
Which nursing advice is appropriate for the family of a child with a respiratory tract infection that is having bouts of vomiting and refuses oral fluids? a. Give thick fruit juice to provide high calorie intake b. Force the child to drink fluids to maintain hydration level c. Offer the child's favorite beverages to promote hydration d. Give oral fluids at fixed intervals even if the child is sleeping
c
Which purpose would potassium chloride added to the intravenous solution of a client with DKA serve? a. Treats hyperpnea b. Prevents flaccid paralysis c. Prevents hypokalemia d. Treats cardiac dysrhythmias
c
Which unique response is associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Fluid loss b. Glycosuria c. Kusssmaul respirations d. Increased blood glucose level
c
While obtaining the client's health history, which factor would the nurse identify as predisposing the client to type 2 diabetes? a. Having diabetes insipidus b. Earing low-cholesterol foods c. Being 20 pounds (9 kg) overweight d. Drinking a daily alcoholic beverage The nurse is educating the client newly diagnosed with type 2 diabetes on oral
c
Which finding indicates a child with acute glomerulonephritis has progressed to renal failure? a. Pleural effusion b. Gross hematuria c. Moderate proteinuria d. Elevated serum potassium levels
d
Which information would the nurse include in teaching about preventing vaginal infection? a. Wear synthetic fabrics b. It is important to douche c. Take all antibiotics as prescribed d. Take all medications for diabetes as prescribed
d
