Cellular Regulation

A client with cancer is receiving leucovorin as part of a chemotherapy protocol. Which purpose does leucovorin serve? 1 Potentiating the effect of alkylating agents 2 Diminishing toxicity of folic acid antagonists 3 Limiting vomiting associated with chemotherapy 4 Preventing alopecia

2 Diminishing toxicity of folic acid antagonists Leucovorin limits toxicity of folic acid antagonists, such as methotrexate sodium, by competing for transport into cells. Leucovorin does not potentiate the effect of alkylating agents. It does not have antiemetic properties. It will not prevent hair loss.

Which lab finding will alert the nurse that aldosterone will be released in a client who has a history with an endocrine disorder? 1 Hypokalemia 2 Hypoglycemia 3 Hyponatremia 4 Hypochloremia

3 Hyponatremia Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? 1.Place the client on protective isolation precautions. 2.Obtain cultures as per the facility's standing policy. 3.Instruct the client to call for help to get out of bed. 4.Assess the client for calf pain, warmth, and redness.

3.Instruct the client to call for help to get out of bed. A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

Which information about common expected responses to computed tomography (CT) scan contrast material would the nurse include in preprocedure teaching? Select all that apply. One, some, or all responses may be correct. 1 Visual disturbances 2 Flushing of the face 3 Sensation of warmth 4 Lemony taste in the mouth 5 Small petechiae on the arms

2 Flushing of the face 3 Sensation of warmth Contrast material precipitates common responses, such as flushing of the face and a sensation of warmth, that indicate sensitivity to the foreign substance. Hypersensitivity reactions (e.g., palpitations, respiratory distress, headache) may occur in some people. Visual disturbances are not caused by a CT scan with contrast material. A salty, not lemony, taste may occur. Petechiae do not result from a CT scan with contrast material.

A nurse is assessing a client with glioblastoma. What assessment is most important? 1. Abdominal percussion 2. Neurologic examination 3. Abdominal palpation 4. Lung auscultation

2. Neurologic examination A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

Which skin infection is treated with an intralesional injection? 1 Impetigo 2 Scabies 3 Alopecia areata 4 Bacterial vaginosis

3 Alopecia areata Alopecia areata is treated with an intralesional injection. Impetigo is treated with mupirocin. Scabies is treated with 5% permethrin topical lotion. Bacterial vaginosis is treated with metronidazole.

A client receives doxorubicin infusions for treatment of acute lymphocytic leukemia. Which clinical finding indicates that toxicity has occurred? 1 Alopecia 2 Dyspnea 3 Metallic taste to food 4 Cardiac rhythm abnormalities

4 Cardiac rhythm abnormalities Doxorubicin is cardiotoxic, which is manifested by transient electrocardiogram (ECG) abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect. Dyspnea and a metallic taste to food are not effects of doxorubicin.

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, which symptom does the nurse expect the client to report? 1 Pruritus 2 Diarrhea 3 Blurred vision 4 Bleeding gums

1 Pruritus Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) 1. Obvious change in a mole 2. Near-daily abdominal pain 3. A sore that does not heal 4. Changes in menstrual patterns 5.Indigestion or trouble swallowing

1. Obvious change in a mole 3. A sore that does not heal 4. Changes in menstrual patterns 5.Indigestion or trouble swallowing The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

A client undergoing treatment for a medical condition gave birth to a baby with renal failure as a result of the teratogenic effect of the medications. The nurse would identify which treatment received by the mother during pregnancy as a potential cause of this teratogenic effect? 1 Cancer 2 Epilepsy 3 Hypertension 4 Microbial infection

3 Hypertension Angiotensin-converting enzyme inhibitors used for treating hypertension may cause renal failure as a teratogenic effect. Treatment of cancer may cause central nervous system malformations. Treatment of epilepsy may cause growth delay. Antimicrobials may cause heart defects.

Which clinical manifestation would the nurse expect to find in a client with a new diagnosis of acute lymphocytic leukemia (ALL)? 1 Alopecia 2 Insomnia 3 Ecchymosis 4 Hypertension

3 Ecchymosis Bleeding tendencies as shown in ecchymosis occur because of thrombocytopenia associated with overproduction of rapidly proliferating leukocytes. Alopecia is associated with chemotherapy; there is no change in hair with leukemia. Because fatigue is associated with ALL, the client may be sleeping more than usual, not less as with insomnia. Hypertension is not a clinical manifestation of leukemia.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client? A. Sodium: 143 mEq/L B. Potassium: 2.9 mEq/L C. Bicarbonate: 25 mEq/L D. Total calcium: 10 mg/dL

B. Potassium: 2.9 mEq/L The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is less than the normal level. It may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL.

A client at 26 weeks' gestation arrives at the clinic for her scheduled examination. Blood pressure is 150/86 mm Hg and there has been a 5-lb (2.3-kg) weight gain in the past 2 weeks. Which nursing action is necessary? 1 Testing the client's urine for albumin 2 Taking the client's body temperature 3 Preparing the client for a vaginal examination 4 Scheduling the client for an appointment in a week

1 Testing the client's urine for albumin Albumin (a protein made by the liver) in the urine can be an indication of preeclampsia, as are increased blood pressure and weight gain of more than 2 lb (0.9 kg) per week. Changes in body temperature are not associated with preeclampsia. Evaluation does not require a vaginal examination at this time. Scheduling the client for an appointment in a week is premature. More data must be collected, documented, and evaluated before a course of action is determined.

Which intervention would the nurse teach a client scheduled for a subtotal gastrectomy for stomach cancer to minimize postoperative dumping syndrome? 1 Ambulate after every meal. 2 Remain on a diet low in fat. 3 Eat 5 or 6 small meals per day. 4 Increase fluid intake when eating food.

3 Eat 5 or 6 small meals per day Eating smaller meals 5 to 6 times per day reduces the chance of a large amount of food emptying too quickly into the duodenum. Ambulating after meals speeds gastric emptying and should be avoided. A diet low in fat speeds gastric emptying and should be avoided. Clients should avoid increasing fluid intake when eating food, because the fluids speed gastric emptying.

Which statement made by the nurse is correct regarding the absorption of medications in pediatrics? 1 "Gastric emptying time is delayed in early infancy, which affects absorption." 2 "Medication absorption after intramuscular injection is rapid in the neonate." 3 "Gastric acidity reaches adult values in 1 year of age, which affects absorption." 4 "Infants have thinner skin and are at a higher risk for toxicity when transdermal administration is used."

4 "Infants have thinner skin and are at a higher risk for toxicity when transdermal administration is used." Blood flow to the skin is higher in infants because they have thinner skin, so medication absorption is rapid through transdermal administration. This causes increased risk of toxicity. Gastric emptying time is prolonged and irregular in early infancy, enhancing absorption. Medication absorption through intramuscular injection is slow and erratic. Although lower gastric acidity does affect absorption, gastric acidity in children doesn't reach adult values until 2 years of age.

Which condition would the nurse suspect if a client's laboratory reports show white blood cells (WBCs) in the urine? 1 Pyelonephritis 2 Kidney trauma 3 Kidney infection 4 Acute tubular necrosis

3 Kidney infection The presence of WBCs in the urine indicates a kidney or urinary tract infection. The presence of red blood cells in the urine indicates pyelonephritis, kidney trauma, or acute tubular necrosis.

Which instructions by the nurse will be beneficial to the client prescribed pyrazinamide for tuberculosis? Select all that apply. One, some, or all responses may be correct. 1 "Avoid drinking alcoholic beverages while taking this medication." 2 "Drink at least 8 ounces of water with each dose of the medication." 3 "If you wear your soft contact lenses, they will be permanently stained." 4 "Darkening of the urine is normal while you are using this medication." 5 "Be sure to report any vision changes, such as diminished color perception."

1 "Avoid drinking alcoholic beverages while taking this medication." 2 "Drink at least 8 ounces of water with each dose of the medication." A client undergoing pyrazinamide therapy may require extra fluids to help prevent uric acid formation from precipitating and causing gout or kidney problems. The client should drink at least 8 ounces of water with the medication. The client should also avoid alcoholic beverages, which could potentiate liver toxicity. Staining is a common problem with rifampin, not pyrazinamide. The client should also report any darkening of urine because this may be a sign of liver toxicity or damage. The client should report any vision changes if taking ethambutol.

When teaching a client with tuberculosis about prescribed medications, which statements would the nurse use regarding isoniazid? Select all that apply. One, some, or all responses may be correct. 1 "Be sure to take the medication on an empty stomach." 2 "Report any changes in vision to your primary health care provider." 3 "Take daily multiple vitamins that contain B complex." 4 "Wear protective clothing when going outdoors during the day." 5 "Report darkening of your urine or a yellowish skin discoloration."

1 "Be sure to take the medication on an empty stomach." 3 "Take daily multiple vitamins that contain B complex." 5 "Report darkening of your urine or a yellowish skin discoloration." Isoniazid should be taken on an empty stomach because food prevents absorption of the medication. Multiple vitamins that contain the vitamin B complex should be taken along with isoniazid because the medication depletes vitamin B. A client on isoniazid should report darkening of the urine and yellowish skin discoloration because these conditions are signs of liver toxicity. A client on ethambutol should be taught to report changes in vision. A client on pyrazinamide is instructed to wear protective clothing when anticipating exposure to sunlight.

Which assessment findings are associated with Cushing disease? Select all that apply. One, some, or all responses may be correct. 1 Round face 2 Dependent edema in the feet and ankles 3 Increased fatty deposition in the extremities 4 Thin, translucent skin with bruising 5 Increased fatty deposition in the neck and back

1 Round face 2 Dependent edema in the feet and ankles 4 Thin, translucent skin with bruising 5 Increased fatty deposition in the neck and back Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition.

Which assessment findings would indicate the need for atenolol in a client diagnosed with hyperthyroidism? Select all that apply. One, some, or all responses may be correct. 1 Tachycardia 2 Atrial fibrillation 3 Distant heart sounds 4 Systolic hypertension 5 Decreased cardiac output

1 Tachycardia 2 Atrial fibrillation 4 Systolic hypertension In hyperthyroidism, atenolol is prescribed to reduce cardiac manifestations. Tachycardia, atrial fibrillation, and systolic hypertension are cardiac manifestations associated with hyperthyroidism. Distant heart sounds are associated with hypothyroidism. The cardiac output is increased in hyperthyroidism.

A client receiving chemotherapy develops bone marrow suppression. The nurse will monitor for which thrombocytopenic effect? Select all that apply. One, some, or all responses may be correct. 1 Deep vein thrombosis 2 Melena 3 Purpura 4 Emboli 5 Hematuria

2 Melena 3 Purpura 5 Hematuria Black, tarry feces caused by the action of intestinal secretions on blood are associated with bleeding in the gastrointestinal tract; bleeding is related to a reduced number of thrombocytes, which are part of the coagulation process. Hemorrhages into the skin and mucous membranes (purpura) may occur with reduced numbers of thrombocytes, which are part of the coagulation process. Blood in the urine (hematuria) may occur with a reduced number of thrombocytes, which are part of the coagulation process. Deep vein thrombosis and emboli are effects of thrombocytosis.

The nurse suspects metastasis in a client with stage I seminoma who has just undergone biopsy. Which test is most appropriate for detecting the spread of cells in this client? 1 Ultrasonography 2 Alpha fetoprotein 3 Computed tomography 4 Lactase dehydrogenase

3 Computed tomography Stage I seminoma is a common type of testicular cancer. Testicular biopsy is not recommended because it may cause the spread of malignant cells (i.e., metastasis). Computed tomography (CT) is the most appropriate means of detecting metastases. Ultrasonography is beneficial in determining whether a mass is intratesticular. Alpha fetoprotein and lactase dehydrogenase are the serum tumor markers that should be assayed when a testicular mass is found to be intratesticular.

A client is diagnosed with pheochromocytoma. Which finding in the urinalysis report supports the diagnosis? 1 Sodium: 200 mmol/24 h 2 Calcium: 5.6 mmol/24 h 3 Urea nitrogen: 0.5 mmol/24 h 4 Total catecholamines: 640 mmol/24 h

4 Total catecholamines: 640 mmol/24 h Total catecholamines increase as a result of pheochromocytoma, stress, neuroblastoma, and heavy exercise. A total catecholamine level below 591 mmol/24 h is normal. The client's report shows 640 mmol/24 h of total catecholamines, which is higher than the normal range. The total catecholamine levels in the client's urinalysis report suggest pheochromocytoma. Sodium concentrations in the range of 40 to 220 mmol/24 h are normal. The client has a sodium concentration of 200 mmol/24 h, which is a normal finding. The normal levels of calcium in the urine range between 2.5 and 7.5 mmol/24 h. The client has a calcium concentration of 5.6 mmol/24 h, which is a normal value. The normal values of urea nitrogen range from 0.43 to 0.71 mmol/24 h. The client has a urea nitrogen level of 0.5 mmol/24 h, which is a normal finding.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? 1.Filgrastim (Neupogen) 2.Mesna (Mesnex) 3.Epoetin alfa (Epogen) 4.Oprelvekin (Neumega)

3.Epoetin alfa (Epogen) The client's hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.

A client reports a fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea. Which organism would the nurse associate with these clinical manifestations? 1 Influenza virus 2 Toxoplasma gondii 3 Human herpesvirus-8 4 Cryptosporidium muris

1 Influenza virus Fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea are symptoms of influenza. Influenza is caused by the Influenza virus. Toxoplasma gondii causes fever, altered mental status, headache, and seizures. Human herpesvirus-8 causes vascular lesions on the skin. Cryptosporidium muris causes watery diarrhea and weight loss.

A client with an inoperable cancer of the head of the pancreas involving the common bile duct has a T-tube inserted. During the first 48 hours after insertion of the tube, which is an appropriate nursing intervention? 1 Maintain T-tube patency via gravity drainage. 2 Use normal saline to irrigate the T-tube every 2 hours. 3 Ensure that the T-tube is connected to low, intermittent suction. 4 Avoid positioning the client on the right side where the T-tube is located.

1 Maintain T-tube patency via gravity drainage. A T-tube drains by gravity into a small collection bag; the right side-lying or the semi-Fowler position enhances gravity drainage. A T-tube is not irrigated; it drains by gravity. A T-tube drains by gravity, not intermittent suction. The right side-lying position facilitates drainage and should be encouraged.

A client undergoes surgical implantation of radon seeds for oral cancer. The nurse would observe the client for which side effects? 1 Nausea or vomiting 2 Hematuria or occult blood 3 Hypotension or bradycardia 4 Abdominal cramping or diarrhea

1 Nausea or vomiting The mucosa of the mouth and the vomiting center in the brain stem may be affected, producing nausea and vomiting. Hematuria, occult blood, hypotension, and bradycardia are not side effects of radiation therapy related to the oral cavity. Neither abdominal cramping nor diarrhea is an expected response because of the distance between the radon seeds and the intestines.

Which adverse effect of heparin would the nurse assess a client for during pregnancy? 1 Osteoporosis 2 Severe bleeding 3 Abnormal uterine contractions 4 Suppression of uterine contractions

1 Osteoporosis Heparin is safe to a fetus but may cause osteoporosis in a pregnant woman. Severe bleeding and abnormal or suppressed uterine contractions are not associated with heparin.

The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client? 1 Permanent sigmoid colostomy 2 Permanent ascending colostomy 3 Temporary double-barrel colostomy 4 Temporary transverse loop colostomy

1 Permanent sigmoid colostomy When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon (abdominoperineal resection), a permanent colostomy is formed. The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. Temporary double-barrel colostomy is performed to allow a segment of colon to heal; intestinal continuity is restored eventually. Temporary transverse loop colostomy commonly is performed for inflammation of the colon when intestinal continuity eventually can be restored.

Which goals are appropriate when caring for a client with hyperplasia of pituitary tissue? Select all that apply. One, some, or all responses may be correct. 1 To alleviate headache 2 To replace lost sodium 3 To eliminate visual disturbances 4 To check the urine specific gravity 5 To return hormone levels to normal

1 To alleviate headache 3 To eliminate visual disturbances 5 To return hormone levels to normal A client with hyperplasia of pituitary tissue (tissue overgrowth) will have oversecretion of pituitary hormones resulting in hyperpituitarism. The client with hyperpituitarism will experience headaches and changes in vision; thus the goal of management should be to have normal pituitary hormone levels. Replacement of lost sodium is important if the client has syndrome of inappropriate antidiuretic hormone secretion. The specific gravity of urine may be low in certain conditions such as hyperaldosteronism.

A client experienced a wheal and flare reaction to a skin test after a mosquito bite. Which type of hypersensitivity reaction did the client experience? 1 Type I 2 Type II 3 Type III 4 Type IV

1 Type I Type I is an immunoglobulin E (IgE)-mediated hypersensitivity reaction that causes a wheal and flare response. A type I reaction displays a pale wheal containing edematous fluid surrounded by a red flare from the hyperemia. Type II is a cytotoxic hypersensitivity reaction involving IgG and IgM antibodies but does not show a wheal and flare response. Type III hypersensitivity reaction is an immune complex-mediated reaction involving erythema and edema within 3 to 8 hours. The type IV hypersensitivity elicits a delayed hypersensitivity reaction involving erythema and edema within 24 to 48 hours of exposure.

Which condition would be suspected in a 17-year-old client in whom secondary sexual characteristics and menarche have failed to occur? 1 Amenorrhea 2 Endometriosis 3 Dysmenorrhea 4 Premenstrual syndrome

1 Amenorrhea Amenorrhea is the absence of menstruation or development of secondary sexual characteristics even after late adolescence. Endometriosis is characterized by the presence and growth of endometrial tissue outside of the uterus. Dysmenorrhea is pain during or shortly before menstruation. Mood swings and somatic symptoms that occur with the menstrual cycle are considered components of premenstrual syndrome.

Which assessment finding indicates hypersecretion of adrenocorticotrophic hormone? 1 Moon face 2 Lower jaw protrusion 3 Heat intolerance 4 Barrel-shaped chest

1 Moon face Hypersecretion of adrenocorticotrophic hormone results in Cushing disease, which is characterized by "moon face" appearance, an abnormal distribution of fat in the face. Protrusion of the lower jaw is a feature of acromegaly, caused by excess secretion of growth hormone. Heat intolerance is seen in clients with excess secretion of thyrotropin. In acromegaly, the client presents with "barrel-shaped" chest appearance.

While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. Which nursing intervention helps prevent complications associated with this condition? 1 Providing thorough perineal care after each voiding 2 Encouraging the client to use the toilet or bedpan every 2 hours 3 Responding quickly to the client's indication of the need to void 4 Applying voiding stimulants to the perineum

1 Providing thorough perineal care after each voiding Weakened urinary sphincters and shortened urethras are age-related physiological changes in older adults. Because a shortened urethra has an increased potential for bladder infections, the nurse should provide thorough perineal care after each voiding. Encouraging the client to use the toilet or bedpan every 2 hours will help avoid overflow urinary incontinence. Responding quickly to the client's indication of the need to void will help alleviate urinary stress incontinence episodes. Applying voiding stimulants to the perineum will help initiate voiding in the client.Test-Taking Tip: Recall the effect on weakened urinary sphincters and shortened urethra in the client and choose the correct answer.

A woman with chronic asthma discontinues her medication during pregnancy. Which condition would the nurse anticipate as likely to occur in the newborn? 1 Stillbirth 2 Down syndrome 3 Ebstein anomaly 4 Gray baby syndrome

1 Stillbirth The risk of stillbirth is very high in women who discontinue asthma medication during pregnancy. Down syndrome is a genetic disorder that is caused by the presence of an extra chromosome 21. Ebstein anomaly is a cardiac birth defect that is caused by lithium use during pregnancy. Intravenous administration of chloramphenicol during pregnancy may cause gray baby syndrome.

The charge nurse notifies you that you will be receiving a new client from the ER who has an ANC of 1800 mm3 . What will you need to do to prepare for their arrival? Select all that apply. 1.Ensure equipment used for patient such as stethoscope stays in room. 2.Ensure the client is placed in a room with negative pressure. 3.Call dietary to ensure nofresh fruits or vegetables are served to client 4.Place a sign on the door "No Visitors"

1.Ensure equipment used for patient such as stethoscope stays in room. 3.Call dietary to ensure nofresh fruits or vegetables are served to client The client should be placed in a private room, it does not need to be a negative pressure room. The door must remain closed with a sign indicating all visitors must see nurse before entering. Family is not discouraged from visiting, they need to follow standard precaution guidelines. If visitors are sick, they are required to wear a mask and possibly a gown and gloves. No fresh fruits, vegetables, or flowers in the room are allowed. Equipment used for patient care should remain in room, or thoroughly sterilized between patients.

According to the Centers for Disease Control and Prevention (CDC) classification, which laboratory report enables the nurse to conclude a client has a stage 3 human immunodeficiency virus (HIV) infection? Select all that apply. One, some, or all responses may be correct. 1 CD4 + T-cell count 800 cells/mm 3 or a percentage of 32% 2 CD4 + T-cell count 100 cells/mm 3 or a percentage of 11% 3 CD4 + T-cell count of an unknown percentage and Kaposi sarcoma 4 CD4 + T-cell count of an unknown percentage and Burkitt lymphoma 5 CD4 + T-cell count 150 cells/mm 3 or a percentage of 12% and Kaposi sarcoma

2 CD4 + T-cell count 100 cells/mm 3 or a percentage of 11% 5 CD4 + T-cell count 150 cells/mm 3 or a percentage of 12% and Kaposi sarcoma The CDC has classified four stages of HIV infection. Stage 3 is characterized by a CD4 + T-cell count less than 200 cells/mm 3 or a percentage less than 14%. A T-cell count of greater than 500 cells/mm 3 or a percentage of 29% or greater is regarded as stage 1 HIV. A client whose HIV infection is confirmed with no information on the CD4 + T-cell count but who has an acquired immunodeficiency syndrome-defining illness such as Kaposi sarcoma or Burkitt lymphoma is considered to be in stage 4 HIV.

A client with Lyme disease presents with dyspnea, dizziness, and facial paralysis. Which prescribed medication would the nurse teach this client? 1 Amoxicillin 2 Ceftriaxone 3 Doxycycline 4 Erythromycin

2 Ceftriaxone Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi. It results from the bite of an infected deer tick, also known as the blacklegged tick. Stage II of Lyme disease is characterized by dizziness, dyspnea, and facial paralysis, and may be treated with ceftriaxone. Amoxicillin, doxycycline, and erythromycin are prescribed to treat localized stage I Lyme disease.

For which side effects would the nurse monitor in the client receiving methyldopa for hypertension? 1 Xerostomia 2 Hemolytic anemia 3 Thrombocytopenia 4 Lupus-like syndrome

2 Hemolytic anemia Methyldopa is used in the treatment of hypertension. The medication can be a precipitating factor in an autoimmune disease such as hemolytic anemia. Scopolamine transdermal, an anticholinergic, may cause dry mouth or xerostomia. Chemotherapy medications, such as mycophenolate mofetil and azathioprine, can cause thrombocytopenia. Procainamide is an antiarrhythmic agent that can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.

What information from a client's history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct. 1 Hemorrhoids 2 Increased age 3 High-fiber diet 4 Ulcerative colitis 5 Low hemoglobin level

2 Increased age 4 Ulcerative colitis A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.

A client with follicular non-Hodgkin's lymphoma is to be treated with rituximab, a targeted monoclonal antibody. The nurse will monitor the client for which common side effect of rituximab? 1 Polyphagia 2 Leukopenia 3 Constipation 4 Hypertension

2 Leukopenia Rituximab targets the CD 20 antigen, which regulates cell cycle differentiation and is found on malignant B lymphocytes; as a result, rituximab therapy can cause leukopenia and neutropenia. Anorexia, not polyphagia, may occur with rituximab therapy. Frequent stools and diarrhea, not constipation, may occur with rituximab therapy. Hypotension, not hypertension, may occur as a fatal infusion reaction to rituximab therapy.

The nurse notes cutaneous fibromas and Lisch nodules (yellow elevations) on a client's irises. Which genetic condition might this client have? 1 Phenylketonuria 2 Neurofibromatosis 3 Huntington disease 4 Myotonic dystrophy

2 Neurofibromatosis Cutaneous fibromas and Lisch nodules (yellow elevations on the iris) are signs of neurofibromatosis. Growth failure, frequent vomiting, irritability, hyperactivity, and erratic behavior are signs of phenylketonuria. Huntington disease is a progressive neurodegenerative disease. Muscle weakness, wasting, myotonia, and cardiac conduction abnormalities are signs of myotonic dystrophy.

A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. Which consideration is priority when the nurse is planning room placement? 1 Assign the client to any type of room. 2 Place the client in a private room. 3 Assign the client to a semiprivate room. 4 Place the client with another client receiving the same type of therapy.

2 Place the client in a private room. Radon seeds emit radiation; the client should be isolated in a private room to decrease radiation to others. Assigning the client to any type of room is inappropriate and unsafe because the treatment emits radiation. A semiprivate room is contraindicated because this will expose other clients to radiation. A room with clients receiving the same therapy is contraindicated because this will expose other clients to radiation.

The nurse recalls that which disease in clients includes the short period of the evident decline in disease trajectory? 1 Heart failure 2 Renal cancer 3 Disabling stroke 4 Alzheimer disease

2 Renal cancer Clients with cancer follow the short period of the evident decline in disease trajectory. Clients with organ failure do not follow this trajectory; instead, these clients follow the long-term limitations with intermittent serious episodes trajectory. The prolonged dwindling disease trajectory is generally seen in clients with disabling stroke, Alzheimer disease, and frailty disease.

Which topical immunomodulator is used to treat a client with atopic dermatitis? 1 Mupirocin 2 Tacrolimus 3 Clindamycin 4 Erythromycin

2 Tacrolimus Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.

Which assessments would the nurse perform for a woman prescribed clomiphene? Select all that apply. One, some, or all responses may be correct. 1 Allergies to ergot alkaloids 2 Reproductive and uterine status 3 Concomitant use of antidepressants 4 Family stability and economic status 5 Maternal history for estimated gestation

2 Reproductive and uterine status 3 Concomitant use of antidepressants 4 Family stability and economic status The client's reproductive and uterine status should be assessed because clomiphene may result in multiple pregnancies. The concomitant use of antidepressants with clomiphene may cause fertility impairment. Assessing the client's family stability and economic status is essential because this can be a risk factor for multiple pregnancies. Clomiphene is not an ergot alkaloid; therefore, assessing for allergies to ergot alkaloids is not appropriate. Clomiphene is not administered during pregnancy; therefore, assessing the maternal history for estimated gestation of the client is irrelevant.

Which clinical manifestations are associated with Sjögren syndrome (SS)? Select all that apply. One, some, or all responses may be correct. 1 Angioedema 2 Tooth decay 3 Corneal ulcers 4 Vaginal dryness 5 Pulmonary hemorrhage

2 Tooth decay 3 Corneal ulcers 4 Vaginal dryness A client with SS may have antigens specific to certain tissue types, such as HLA-DRW52, HLA-DR3, and HLA-B8. SS may lead to autoimmune destruction of the lacrimal, salivary, and vaginal mucus-producing glands. Insufficient saliva decreases digestion of carbohydrates, which may promote tooth decay. Insufficient tears cause inflammation and ulceration of the cornea. Vaginal dryness increases the risk for infection and causes painful sexual intercourse. Angioedema occurs with a type I hypersensitivity reaction that may occur within seconds after exposure to the allergen. Clients with Goodpasture syndrome may have lung and kidney problems. Pulmonary hemorrhage is associated with Goodpasture syndrome.

Which condition would the nurse anticipate in a client who complains of weight gain and has purplish-blue striae on the abdomen? 1 Hypothyroidism 2 Addison disease 3 Cushing syndrome 4 Pheochromocytoma

3 Cushing syndrome Cushing syndrome occurs because of chronic exposure to excess corticosteroids. Weight gain and purplish-blue striae are the clinical manifestations of Cushing syndrome. Anemia, weight gain, and cold dry skin are the common manifestations of hypothyroidism. Weight loss and fatigue are the manifestations observed in Addison disease. Severe, pounding headache, tachycardia, and profuse sweating are the clinical manifestations observed in pheochromocytoma.

The parents of a 4-year-old child with newly diagnosed acute lymphocytic leukemia (ALL) blames themselves for not seeking care sooner after noticing changes in their child's behavior and the "black and blue" marks. Which response would the nurse provide based on the pathophysiology of leukemia and the typical diagnostic process? 1 The diagnosis can be certain only after a blood smear is analyzed. 2 If leukemia is diagnosed, the child's prognosis is probably guarded. 3 Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. 4 The description of the clinical findings indicates that the child has been ill for longer than a single week.

3 Early signs and symptoms of leukemia are similar to those of other mild illnesses of childhood. To allay parental guilt and anxiety, it is important to acknowledge how difficult it is to recognize severe illness on the basis of changes in the child's behavior and ecchymoses that can result when a child bangs into an object, a common occurrence in young children. A bone marrow aspiration or biopsy is required for a definitive diagnosis. ALL in children has a favorable prognosis, depending on several factors, including the child's age at diagnosis, the white blood cell count, and the type of cell involved. Even if the parents missed the fact that their child was so ill, mentioning this may cause more anxiety and guilt and interfere with the development of nurse-client rapport.

Which diagnostic test determines the specific cause of a client's allergic reaction? 1 Perform eosinophil count 2 Perform white blood cell count 3 Perform radioimmunosorbent test (RIST) 4 Perform enzyme-linked immunosorbent assay (ELISA)

3 Perform radioimmunosorbent test (RIST) The blood levels of immunoglobulin E (IgE) directed against a specific allergen can be estimated by the RIST. RIST is helpful to diagnose a specific cause for an allergic reaction. The eosinophil count increases in cases of allergic reactions; however, this count cannot ascertain a specific cause for the allergy. The white blood cell count can help determine the presence of an allergy but not the cause. The serum IgE levels are measured by the ELISA test; this test only indicates the presence of an allergy.

The clinic nurse instructs a client to discard the morning first-voided urine, then collect a fresh urine specimen and transport it to the laboratory within 1 hour of collection. Which diagnostic procedure requires this process? 1 Residual urine 2 Concentration test 3 Urine cytology 4 Protein level

3 Urine cytology For urine cytologic study, the morning's first-voided specimen is not used because epithelial cells may change in appearance in the urine held in the bladder overnight. Urine cytologic study requires this intervention with a fresh urine sample. Residual urine tests, concentration tests, and protein determination tests do not require this intervention. Catheterization or bladder ultrasound equipment are used in a client prescribed with a residual urine test after the client has voided. The concentration test requires the client to fast after a given time in the evening and then three urine specimens are collected in hourly intervals. A dipstick may be used to test the protein levels in the urine.

To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply. One, some, or all responses may be correct. 1 Monitor for signs of alopecia. 2 Encourage an increase in fluids. 3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately. 6 Teach the client to avoid eating raw fruits or vegetables.

3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately. Bone marrow depression causes neutropenia; it is essential to prevent infection in this client by thorough hand washing before touching the client or client's belongings. Thrombocytopenia occurs with chemotherapy-induced bone marrow depression; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary health care provider immediately because it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. Clients who have neutropenia may eat raw fruits and vegetables after washing off soil that may contain disease-causing microbes.

A client who has multiple myeloma tells the nurse about plans for airline travel to visit family members. Which topic will the nurse include in discharge planning? 1 Avoidance of travel to prevent fatigue 2 Need to restrict fluid intake when flying 3 Ways to prevent infection during travel 4 How to fill prescriptions away from home

3 Ways to prevent infection during travel Prevention of infection is important in this client with impaired bone marrow production of leukocytes and immunoglobulins. Fatigue is a concern with multiple myeloma, but travel can be managed with careful planning and use of rest periods. Increased fluid intake is needed with airline travel, because dehydration should be avoided due to the risk for kidney stones and renal failure with multiple myeloma. The nurse would assist the client to be sure all prescriptions were filled before leaving home, because it can be difficult to fill prescriptions when traveling to different states or countries.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? 1.Educating the client on side effects 2.Monitoring the client for nausea 3.Assessing the IV site every hour 4.Providing warm packs for comfort

3.Assessing the IV site every hour Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.

Which wound care is given to a client with severe burn injuries during the acute phase? 1 Assess extent and depth of burns. 2 Provide daily shower and wound care. 3 Remove dead and contaminated tissue. 4 Assess the wound daily and adjust the dressing.

4 Assess the wound daily and adjust the dressing. In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debriding) is performed in the emergent phase.

Which intervention would the nurse complete first for the client found to have glucose in the urine? 1 Administering oral fluids 2 Planning to teach the client about diabetes 3 Giving hypoglycemic medication 4 Reporting the finding to the primary health care provider

4 Reporting the finding to the primary health care provider The presence of glucose in the urine is an abnormal finding that requires further assessment. The nurse should report this finding to the primary health care provider. The nurse should not administer oral fluids or hypoglycemic medication without instructions from the primary health care provider. Teaching may be important later if the client is diagnosed with diabetes.

The nurse provides self-care instructions to a client who is receiving external radiation therapy for bone metastases. Which client activity demonstrates a need for further teaching? 1 Protecting the skin from direct sunlight 2 Wearing loose-fitting cotton clothing over the area 3 Drying the area with a patting motion using a soft towel 4 Rubbing on talcum powder after washing the area

4 Rubbing on talcum powder after washing the area Intending to use talcum powder indicates the client needs more teaching. Powders, lotions, creams, and ointments should not be applied to the area unless prescribed; some substances interfere with the path of the radiation and should not be used. The other intended actions are appropriate and do not need follow up. Sun rays, a form of radiation, can damage the skin further and should be avoided. Cotton is a natural fiber that is soft against the skin and allows air to circulate. The skin should be protected by patting dry with a soft towel.

The nurse provides discharge teaching for a client who had a transurethral vaporization of the prostate. Which statement by the client indicates successful learning? 1 "I should sit for several hours throughout the day." 2 "I should attempt to void every 2 hours when I am awake." 3 "I should avoid vigorous exercises for at least 6 months after surgery." 4 "I should notify my primary health care provider if my urinary stream decreases."

4 "I should notify my primary health care provider if my urinary stream decreases." The surgical procedure affects the urethral mucosa in the area of the prostate, and strictures may form with healing. The client should notify his or her primary health care provider if his or her urinary stream decreases. The client should ambulate; sitting for several hours at a time is contraindicated because sitting promotes venous stasis and thrombus formation. The client should void as the need arises; straining to urinate can cause pressure in the operative area, precipitating hemorrhage. Although the client should avoid vigorous exercise immediately after surgery and during the healing process, 6 months is too long for this restriction.

When caring for a client on isoniazid therapy for tuberculosis, the nurse would focus on which diagnostic testing for this client? 1 Creatinine 2 Hearing tests 3 Electrocardiogram 4 Liver function tests

4 Liver function tests Isoniazid can damage the liver enough to lead to death, so liver function should be monitored. Creatinine would be tracked for renal dysfunction, which is not a focus of isoniazid therapy because isoniazid is metabolized by the liver. Aminoglycosides can cause ototoxicity, causing hearing loss. Bedaquiline can cause prolonged QT, detected through electrocardiogram.

Which factor may affect the accuracy of oxygen saturations obtained using pulse oximetry? 1 Fever 2 Obesity 3 Hypertension 4 Nail thickening

4 Nail thickening The accuracy of pulse oximetry may be decreased by factors such as thick nails or nail polish. Fever would not affect accuracy of pulse oximetry, although hypothermia may decrease blood flow to the peripheral system and lead to inaccurately low measurements. Obesity does not affect peripheral blood flow and would not affect accuracy of pulse oximetry readings. Hypertension would not affect accuracy of pulse oximetry, but hypotension may lead to decreased peripheral blood flow and result in inaccurately low readings for pulse oximetry.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? 1. The primary site of the cancer cannot be determined. 2. Regional lymph nodes could not be assessed. 3. There are multiple lymph nodes involved already. 4. There are no distant metastases noted in the report.

4. There are no distant metastases noted in the report. TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

A client is admitted with superior vena cava syndrome with severe dyspnea and decreased level of consciousness. What action by the nurse is most appropriate? 1.Administer a dose of allopurinol (Aloprim). 2.Prepare the client for Thoracentesis. 3.Assess the client's serum potassium level. 4.Gently inquire about advance directives.

4.Gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Thoracentecis would not be done for superior vena cava syndrome.