AEQ's
Which assessment finding would the nurse recognize as common in infants with Down syndrome?
Abnormal heart sounds
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?
Contact dermatitis
Which finding will the nurse identify in most children with symptomatic cardiac malformations?
Delayed growth and development
Which condition would the nurse suspect if the client reports passing urine involuntarily while coughing?
Stress incontinence
The nurse is providing immediate postoperative care to a client who has undergone a total laryngectomy. It is appropriate for the plan of care to include which intervention?
Suctioning the tracheostomy tube whenever necessary
Why is the vomitus of an infant with pyloric stenosis white rather than bile-stained?
There is an obstruction above the opening of the common bile duct
Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker?
Third-degree heart block
Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?
cabbage
Which cardiovascular manifestation is observed in a client with adrenal insufficiency?
hyponatremia
The client with a permanent sigmoid colostomy has colostomy irrigations prescribed and inquires as to why they are prescribed. Which response would the nurse use?
the irrigation helps establish an elimination schedule
The nurse is preparing to administer an oil-retention enema and understands that it works primarily by which action?
Lubricating the sigmoid colon ad rectum
" Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock?
Metabolic acidosis
Question 29 Which assessment finding indicates hypersecretion of adrenocorticotrophic hormone?
Moon Face
Which carcinoma is the most common type of thyroid cancer and is most often found in younger women?
Papillary carcinoma
Which condition results in elevated serum adrenocorticotropic hormone (ACTH) and urine cortisol levels? Diabetes insipidus Adrenal Cushing syndrome Pituitary Cushing syndrome Syndrome of inappropriate antidiuretic hormone
Pituitary cushing syndrome
Which information in the response of a client receiving peritoneal dialysis indicates understanding of the purpose of the procedure?
Removing toxins and metabolic wastes
A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system?
Respiratory
For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?
Respiratory and urinary
Which assessment findings are systemic manifestations of acute osteomyelitis? Select all that apply. One, some, or all responses may be correct.
Malaise Restlessness Night sweats
Which function would the nurse include when teaching a group of student nurses about the loop of Henle?
Reabsorption of sodium in the ascending limb
Which structural defects are associated with tetralogy of Fallot?
Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta
When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)?
inactivity
When a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take?
Encourage deep breathing
Which condition or disease is the current leading cause of death in the United States? Select all that apply. One, some, or all responses may be correct.
Stroke Cancers Accidents
Which condition would be associated with nonpitting edema over the tibia?
endocrine imbalance
The nurse is caring for a client who is vomiting. When caring for this client, the nurse recalls that the vomiting reflex follows a set pattern. List the steps in the order that they occur.
initiate a reverse perilstasis in the stomach Contraction of abd muscles Relaxation of the upper esophageal sphincter Closure of the trachea to prevent aspirtation
Where on the maternal abdomen would the nurse place the fetal heart transducer when the fetus is in the left sacrum anterior position?
Left upper quadrant
After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action?
Administer Oxygen
Which statement by a client who has chronic kidney failure treated with continuous ambulatory peritoneal dialysis (CAPD) indicates understanding of the therapy?
It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion
A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time?
Parenterally replace the clients fluids and electrolyte
Which information about radiation therapy would guide a nurse's response to a 20-year-old female client scheduled to receive pelvic radiation for Hodgkin lymphoma who expresses anxiety about her future ability to conceive a child?
Reproductive abiliy may be preserved through a variety of intervention
Which hypersensitivity condition would the nurse suspect when a client presents with cutaneous lesions, swelling of the face, eyelids, and lips from dilation and engorgement of the capillaries but no observable welts or vesicles?
Angioedema
Which is the purpose of an occlusive dressing over a client's sucking chest wound?
Maintains negative pressure within the cavity
Which clinical manifestation is found in a client with a deficiency of adrenocorticotropic hormone?
Malaise
Question 141 Which condition would the nurse suspect when assessing an 11-month-old infant sitting on the parent's lap crying and tugging at the right ear?
Otitis media
Which skin color change would the nurse expect to see if a client with dark skin develops cyanosis?
gray
Which term will a nurse use to document when a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance? Rest pain Raynaud phenomenon Intermittent claudication Phantom limb sensation
Intermittent claudication
Choanal atresia involves an abnormality of which anatomical structure?
Nasopharynx
Which intestinal obstruction is a concern for hospitalized preterm infants?
Necrotizing enterocolitis
After a subtotal gastrectomy (Billroth I), the client begins eating a variety of food textures and forms. After meals, the client reports cramping discomfort, rapid pulse, and waves of weakness, often followed by nausea and vomiting. Which physiological response does the nurse suspect occurs after the client eats?
Quick passage os hyperosmolar food solution into the small intestine
Which statement would the nurse include when teaching about pneumaturia to a coworker?
It is passage of urine containing gas
An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?
Ketones
Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels?
Aldosterone. Rationale Aldosterone is mineralocorticoid secreted by the adrenal cortex that maintains sodium and water balance. Reduced sodium levels in the client indicate a cortisol imbalance. Additionally, depleted sodium levels in a client indicate hyponatremia. Epinephrine is a catecholamine, which helps in maintaining homeostasis. Glucagon increases blood glucose levels and does not play a role in maintaining electrolyte balance. Calcitonin helps in regulating serum calcium levels.
A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care would be implemented during the postoperative period? Limiting fluid intake f
Keeping the clinets skin around the stoma clean
Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?
encourage coughing and deep breathing
xWhich type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day
Intermittent Rationale An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 100.4°F (38°C). In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.
Question 109 Which stage of syphilis is the client experiencing when there are not any clinical manifestations?
Latent stage
Which response will the nurse give to a client scheduled for radiation treatments Monday through Friday who asks why the treatments will not be given on Saturday and Sunday?
"This type of schedule gives noncancerous cells time to recover."
Which length of time would the nurse teach a client regarding the incubation period of syphilis?
2-6 weeks
Which physiological response explains why elevation in body temperature occurs in clients who experience acute coronary syndrome?
Inflammatory response
How would the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition? An irreversible phenomenon A failure of the circulatory pump Usually a fleeting reaction to tissue injury Generally caused by decreased blood volume
A failure of the circulatory pump
Which action would the nurse take when a client develops epistaxis?
Apply direct lateral pressure to the nose
A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention?
Assess for signs of pneumonia
An adolescent complains of breast pain. Which antigonadotropic herb may alleviate breast pain by decreasing prolactin levels?
Bugleweed
Which disorder would the nurse suspect in the client who has blue nail beds?
Cardiopulmonary disease
A client reports excessive tearing. Which disorders would the nurse suspect could be responsible for the client's condition? Select all that apply. One, some, or all responses may be correct.
Chalazion Entropion Conjunctivitis
Which rationale would the nurse understand for placing a chest tube after an infant's openheart surgery?
Chest tube facilitates drainage of air and fluid
Which information would a nurse provide regarding varicella?
Communicable until all vesicles are dry
Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure?
Crackles
Which statement indicates the cause of posttherapeutic neuralgia in a client with acute herpes zoster treated with antiviral medication within 72 hours of the appearance of the rash who reports persistent pain 1 week later?
Damage to the nerves
Which skin infection does the nurse expect to observe in the electronic medical record of an older adult client with postherpetic neuralgia who reports deep tissue pain?
Herpes Zoster
Which statement would a nurse make about acne in adolescents? Select all that apply. One, some, or all responses may be correct.
Early acne occurs in the midface region Acne usually occurs in middle to late adolescence. Intake of dairy products can contribute to acne severity
Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)?
Electrican burn
Which priority medication will the nurse prepare to administer to the client admitted with acute salmonellosis?
Electrolytes
Which recommendation would the nurse provide to a client with gastroesophageal reflux disease (GERD) who asks how to reduce heartburn and pain without taking medication?
Elevate the head of the bed 5 inches
Which nursing action will help a client obtain maximum benefits after postural drainage?
Encourage coughing deeply
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, which would the nurse emphasize?
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful
Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm?
Hypovolemic
Which statement by a client with pruritus about personal care interventions indicates understanding of the interventions?
I will trim my fingernails regularly
Which statement explains why metabolic acidosis develops with kidney failure?
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
Which clinical feature is indicative of hypercortisolism?
Increase Pigmentation. Rationale Hypercortisolism causes such skin manifestations as increased pigmentation. Weight gain is a characteristic finding in hypercortisolism. The skin becomes thin due to increased fragility of the blood vessels. Loss of bone density is seen in clients with hypercortisolism.
Which instruction would the nurse include in a teaching plan for a client who is taking an oral hypoglycemic daily for type 2 diabetes and is concerned about the need for special care at home if they develop the flu?
Take the oral hypoglycemic pill, drink warm fluids, and check blood sugar before meals and at bedtime
Which information would the nurse include when teaching a client with varicose veins about ligation and stripping surgery?
The dilated saphenous veins are removed
Which considerations would the nurse integrate into the postoperative plan of care of a client scheduled for an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm for hemodialysis?
The graft has a higher risk of hemorrhage, clotting, and infection than the fistula does
Which describes the purpose of preoperative antibiotics for a client scheduled for a surgical resection of the colon and creation of a colostomy?
To decrease bacteria in the intestines
While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. Which event or disorder would the nurse associate with the reason behind this condition?
Trauma
Which precursor would the nurse recognize as common in children who develop Reye syndrome?
Viral infection
A client with a leg fracture is hospitalized. The registered nurse (RN) instructs the nursing student to ask the client to determine the reason for the injury. Which question would help determine an extrinsic factor?
What shoes were you wearing when you fell
