EAQ Unit 3
27. What time of mouth would the nurse teach premenopausal women to perform breast self-examination?
A. When ovulation occurs B. The first day of every month C. The day that the menses begins D. About a week after menses ends
5. Which data collection assessment would be perforemd to evaluate the effectiveness of furosemide administered to a client with congestive heart failure? Select all that apply.
A. Daily weight B. Intake and output C. Monitor for edema D. Daily pulse oximetry E. Ausucltate breath sounds
50. Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine?
A. Dilute urine B. Hematuria C. Concentrated urine D. Myoglobinuria
35. Which manifestation would the nurse expect to find when assessing a client with hyperthyroidism? Select all that apply.
A. Dry skin B. Weight loss C. Tachycardia D. Restlessness E. Constipation F. Exophthalmos
42. Which assessment finding would the nurse expect when a client is diagnosed with left-sided congestive heart-failure? Select all that apply.
A. Dyspnea B. Crackles C. Frequent cough D. Peripheral edema E. Jugular distention
31. Which clinical manifestations would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease?
A. Edema of the feet and ankles B. Reddened and painful areas on the calves C. Pain when exercising and thickening of the toenails D. Ulcers around the ankles and reports of a dull ache in the legs
2. Which findings in a client may indicate potential thyrotoxic crisis?
A. Elevated serum calcium B. Sudden drop in pulse rate C. Hypothermia and dry skin D. Rapid heartbeat and tremors
25. A client is diagnosed with hyperthyroidism and is treated with l-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms would be included in the teaching? Select all that apply.
A. Fatigue B. Dry skin C. Insomnia D. Intolerance to heat E. Progressive weight gain
16. Which activity would the nurse expect to cause the most distress when assessing a client with heart failure for activity tolerance?
A. Getting up from bed in the morning B. Walking to visit the next-door neighbor C. Climbing a flight of stairs to the bedroom D. Leaving the table immediately after a meal
55. Which structure is removed during circumcision?
A. Glans B. Prepuce C. Epididymis D. Vas deferens
45. During a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position?
A. Heart B. Rectum C. Female genitalia D. Musculoskeletal system
17. When the nurse is performing an admission health history and physical assessment for this client, which assessment information is most important to obtain in regard to exophthalmos?
A. Heart rate and rhythm B. Appetite and condition of the skin C. Respiratory rate and depth of inhalations D. Intolerance to heat and decrease in weight
26. Which individual's activities increase the risk of developing carpal tunnel syndrome?
A. Housekeeper B. Software engineer C. Health care worker D. Professional athlete
41. A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. Which would the nurse consider when formulating a response?
A. Hyperthyroidism is a gradual slowing of the body's function. B. A decrease in pituitary thyroid-stimulating hormone (TSH) will occur C. Less thyroid tissue is available to supply thyroid hormone after surgery. D. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.
30. Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply.
A. Impaired memory B. Intolerance to cold C. Difficulty breathing D. Decreased blood pressure E. Decreased body temperature
6. To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care?
A. Increase fluid intake B. Restrict fluids C. Encourage early mobility D. Elevate the foot of the bed
12. One week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis. Which intervention is appropriate to implement for this client?
A. Limit fluid intake. B. Reduce body temperature and heart rate. C. Observe for an exaggerated response to sedatives. D. Treat the associated hyperglycemia and ketoacidosis.
3. Which part of the client's body would the nurse assess to identify osteoporotic changes?
A. Long bones B. Facial bones C. Vertebral column D. Joints of the hands
22. When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?
A. Losing weight over the past week B. Tingling in the upper extremities C. Using several pillows at night to sleep D. Wheezing when exposed to dust or pollen
53. The nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding supports this diagnosis?
A. Melena B. Frank blood C. Fat globules D. Currant jelly consistency
47. Which structure indicated in the figure is the primary reproductive organ of the female?
A. Ovary B. Fallopian tube C. Uterus D. Symphysis pubis
34. Which outcome is likely if the nurse palpates a client's joints during an acute episode of rheumatoid arthritis?
A. Pain B. Swelling C. Nodule formation D. Tophaceous deposits
46. Which structure is included in the external genitalia of the male anataomy? Select all that apply.
A. Penis B. Testes C. Scrotum D. Urethra E. Seminal vesicles
Answer 41 rationale:
After a thyroidectomy, throxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.
Answer 19 rationale:
Altered quantity and quality of pulses are the earliest indications of increasingly limited circulation. Maintaining elevation of both legs prevents the use of gravity to carry arterial blood to the legs and feet. Massaging the legs when painful can release an embolus into the circulation and cause tissue trauma. Altered sensation may limit sensitivity to heat, which can result in burns.
Answer 24 rationale:
Asking what the client knows about breast cancer allows the nurse to assess the client's understanding of breast cancer and to clarify any misconceptions. Saying that they should hope that the growth isn't malignant avoids an opportunity to teach, and it is a type of false reassurance. The statement may actually increase feelings of hopelessness if the lesion is determined to be malignant. Although correct, stating that most lesions are not malignant provides a false sense of security and avoids an opportunity to teach. Asking whether the primary health care provider has told the client that it wasn't cancer focuses on what the primary health care provider said rather than on what the client knows and may limit further communication of feelings and beliefs.
32. Which action would the nurse take next when a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day?
A. Perform a head-to-toe assessment B. Place the client on restricted fluid intake C. Discuss a restricted sodium diet with the client D. Document the findings in the health care record
13. Which position would the nurse place the feet and legs in when caring for a client with peripheral arterial insufficiency?
A. Place them slightly lower than the head and chest. B. Use pillows to support the heels above the mattress. C. Raise the knees using the knee gatch on the bed. D. Elevate feet by raising the foot of the bed on blocks.
14. The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
A. Shift of fluid into the interstitial spaces B. Weakening of the cell wall C. Increased intravascular compliance D. Increased intracellular fluid volume
51. Which urine characteristic is consistent with a urinary tract infection?
A. Smoky B. Cloudy C. Orange-amber D. Yellow-brown
20. The nurse prepares to assess a clients heart during a routine health checkup. In which position would the nurse place the client to assess murmurs of the heart?
A. Supine position B. Lateral recumbent position C. Dorsal recumbent position D. Modified left lateral recumbent position
Answers 1-14:
1. A 2. D 3. C 4. A 5. A, B, C, D, E 6. C 7. B 8. D, E 9. B 10. D 11. B 12. B 13. A 14. A
40. Which clinical manifestation exhibited by a client taking levothyroxine for hypothyroidism for 3 months would cause a nurse to suspect that a decrease in dosage is needed? Select all that apply.
A. Tremors B. Bradycardia C. Somnolence D. Heat intolerance E. Decreased blood pressure
36. Which term would the nurse document in the medical record after assessing the client in the illustration? Fingers are fanned out to the left side.
A. Ulnar drift B. Hallux valgus C. Swan-neck deformity D. Boutonniere deformity
Answers 15-28:
15. C 16. C 17. A 18. D 19. D 20. B 21. A, D, E 22. C 23. A 24. B 25. A,B, E 26. B 27. D 28. C
11. Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen fingers?
A. Urate crystals in the synovial tissue B. Inflammation in the joint's synovial lining C. Formation of bony spurs on the joint surfaces D. Deterioration and loss of articular cartilage joints
Answers 29-42:
29. A,D 30. B, E 31. C 32. A 33. A 34. A 35. B, C, D, F 36. A 37. D 38. A 39. B 40. A, D 41. C 42. A, B, C
4. Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure?
A. Weighing the client B. Monitoring intake and output C. Assessing the extent of pitting edema D. Asking the client about subjective symptoms
44. Which assessment finding is consistent with a client diagnosis of right-sided heat failure? Select all that apply.
A. Collapsed neck veins B. Distended abdomen C. Dependent edema D. Decreased appetite E. Cool extremities
Answer 23 rationale:
A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outward away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines.
Answer 38 rationale:
A corn is a foot disorder caused by continual pressure over bony prominences. A plantar wart is a foot disorder caused by flexion and deformity in the joints. Hallux rigidus is caused by osteoarthritis.
Answer 9 Rationale
A postmenopausal woman who is small-boned, underweight (BMI 18), and relatively sedentary (paralegal) is at risk for osteoporosis; other risk factors are family history and white or Asian ethnicity. A woman who is relatively heavy (BMI 27.1) and does not smoke is at less risk for osteoporosis than is a thin postmenopausal woman. Postmenopausal women who are black are at lower risk for osteoporosis than are white and Asian women. A woman who takes a daily calcium supplement is at less risk for osteoporosis than a woman who does not take a calcium supplement.
Answer 27 rationale:
A week after the end of menses, breast engorgement has abated, limiting lumps that may occur because of fluid accumulation. Breast engorgement begins before ovulation and does not subside until several days after menses ends; engorgement interferes with accurate palpation. Inaccurate assessment may result when examinations are performed at different times of the menstrual cycle because accurate comparisons may not be made from month to month.
52. Which statement would the nurse use to respond to an older adult client who states, "I walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated?"
A. "Drink fruit juices if you start to feel dehydrated." B. "Thirst is a good guide to use to determine fluid intake." C. "Fluids should be increased if the urine becomes darker." D. "Water should be consumed when the skin becomes dry."
38. Which foot disorder is caused by continual pressure over bony promiinences?
A. Corn B. Wart C. Hammertoe D. Hallux rigidus
54. The nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.
A. "I can eat potatoes at dinner daily." B. "I should drink at least six glasses of water a day." C. "I should eat eggs for breakfast three times a week." D. "I can conclude bran muffins in my breakfast daily." E. "I will walk every day as aprt of my exercise regimen."
43. Which client statement indicates a risk of breast cancer? Select all that apply.
A. "I had a late onset of menarche." B. "My first child was born when I was 32." C. "I noticed a slight discharge from a nipple." D. "I perform breast self-examinations frequently." E. "I consume two to four glasses of alcohol a day."
49. After teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs), which client statement indicates effective learning?
A. "I will use condoms when having sex with an infected partner." B. "I will perform a self-examination of my genitals every month before bathing." C. "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." D. "I will consult with my primary health care provider when there is arash or ulcer on my genitalia."
24. A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can't be cancer, because it doesn't hurt." Which response by the nurse is most therapeutic?
A. "Let's hope that it isn't malignant" B. "What do you know about breast cancer?" C. "Most lumps are in the breast are not malignant" D. "Has your primary health care provider told you that it wasn't cancer?"
19. Which instruction will the home health nurse give when teaching a client with arterial insufficiency of both lower extremities?
A. "Maintain elevation of both legs." B. "Massage the legs when they are painful." C. "Apply a hot water bottle to the legs." D. "Check pulses in the legs regularly."
48. An older adult male client asks about the risks of having osteoporosis. Which response would the nurse make?
A. "This is only a problem for females." B. "Start exercising to prevent this problem." C. "You are not at risk because of your small frame." D. "You might consider having a bone density test."
1. A client is experiencing thyrotoxic crisis tells the nurse "I know I'm going to die. I'm very sick." Which is the best response by the nurse?
A. "You must feel very sick and frightened." B. "Tell me why you feel you are going to die" C. "I can understand how you feel, but people do not die from this problem." D. "If you would like, I will call your family and tell them to come to the hospital."
10. The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial mallelus area, noting a 8-mm depression after release. In which way would the nurse document the edema?
A. 1+ B. 2+ C. 3+ D. 4+
39. A client had surgery on the shoulder, and the nurse is to obtain a brachial pulse. Where on the illustration would the nurse indicate to best obtain the brachial pulse rate?
A. A (upper arm, below armpit) B. B (mid arm) C. C (slightly above wrist) D. D (wrist area)
9. Which client is most at risk for osteoporosis?
A. A nonsmoking 60-year-old woman, body mass index 27.1
18. Which finding is more likely to indicate a malignancy in a 38-year-old client admitted for a biopsy of a breast lump?
A. A soft mass that is movable and nontender B. Hard, hot, reddened areas that are tender and painful C. Multiple bilateral lesions that are well-delineated and movable D. A lesion in the upper outer quadrant that is poorly delineated and immobile
29. Which assessment finding will the nurse expect when caring for a client with peripheral artery disease? Select all that apply.
A. Absence of hair on the toes B. Pink and moist ankle ulcers C. Pitting edema of the lower legs D. Reports of pain associated with exercising E. Increased pigmentation of medial malleolus area
28. Which nursing intervention is correct for a client with venous insufficiency?
A. Apply abdominal binder as needed B. Remove compression stockings for client ambulation C. Elevate the client's legs above heart rate D. Keep the upper extremities elevated
37. Which condition can be identified in a client using Phalen's test?
A. Atrophy B. Bone tumor C. Rotator cuff injury D. Carpal tunnel syndrome
23. While assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?
A. Bruit B. Ectropion C. Entropion D. Borborygmi
8. To assess the status of circulation to the foot, which site would the nurse monitor for a pulse? Select all that apply.
A. Carotid artery B. Femoral artery C. Popliteal artery D. Dorsalis pedis artery E. Posterior tibial artery
15.While auscultating the heart, a health care provider notices S 3 heart ounds in four clients. Which client has the highest risk for heart ailure?
A. Child client B. Pregnant client C. Older adult client D. Young adult client
21. Which factors contribute to development of osteoporosis in female clients? Select all that apply.
A. Cigarette smoking B. Moderate exercise C. Use of street drugs D. Familial predisposition E. Inadequate intake of dietary calcium
33. The nurse assesses four clients with foot disorders. Which client would the nurse instruct to use bunion pads to relieve pressure on the bursal sac. Client A: Hallux valgus Client B: Hallux rigidus Client C: Corn Client D: Pes planus
A. Client A B. Client B C. Client C D. Client D
7. Based upon the provided data, which client would the nurse suspect of having hypertension? -Client A: Decreased cardiac output, normal peripheral resistance, decreased hematocrit -Client B: Increased cardiac output, Increased peripheral resistance, Increased hematocrit -Client C: Decreased cardiac output, normal peripheral resistance, normal hematocrit -Client D: Normal cardiac output, increased peripheral resistance, normal hematocrit
A. Client A B. Client B C. Client C D. Client D
Answer 4 Rationale
Because 1 liter of fluid weighs approximately 2.2 pounds (1 kg), daily weights are the best way to monitor fluid volume status. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client. Subjective symptoms such as dyspnea may vary for other reasons than fluid balance status.
Answer 26 rationale:
Carpal tunnel syndrome is a painful condition of the hands and fingers that is caused by repetitive movements that lead to compression of the medial nerve near the wrist. Computer-related jobs involve repetitive movement of the fingers and hand, thereby predisposing the individual to carpal tunnel syndrome. Musculoskeletal injuries can occur in clients whose jobs require manual labor, such as housekeepers and mechanics. Health care workers may be at risk for developing back injury caused by prolonged standing and excessive lifting. Professional athletes experience acute musculoskeletal injuries, such as joint dislocations and fractures.
Answer 21 rationale:
Cigarette smoking is a high-risk behavior associated with an increased incidence of osteoporosis in later life. Familial predisposition is considered a risk factor for the development of osteoporosis. Inadequate calcium intake during the premenopausal years is a risk factor for the development of osteopotosis after menopause. Moderate exercise is not considered a risk factor for the development of osteoporosis, although a sedentary lifestyle is. Use of street drugs is not considered a risk factor for osteoporosis.
Answer 30 rationale:
Cold intolerance and decreased body temperature are the metabolic manifestations observed in a client with hypothyroidism. Impaired memory is the neurological manifestation of hypothyroidism. Difficulty in breathing is the pulmonary manifestation observed in a client with hypothyroidism. Decreased blood pressure is the cardiovascular manifestation observed in a client with hypothyroidism.
Answer 3 Rationale:
Compression fractures of the vertebrae are the most common fractures in clients with osteoporosis; gradual collapse of vertebrae may be asymptomatic and observed as kyphosis. Long bones and facial bones are not observable to the naked eye; joints in the bones is associated with arthritis.
Answer 5 Rationale
Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.
Answer 10 Rationale
Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse would assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8-mm depression. A grade of 1+ indicates a 2-mm depression. A grade of 2+ indicates a 4-mm depression. A grade of 3+ indicates a 6-mm depression.
Answer 14 Rationale
Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathological reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.
Answer 40 rationale:
Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, heat intolerance, tachycardia, hypertension, and insomnia. These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.
Answer 25 rationale:
Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.
Answer 13 Rationale
Gravity will assist the flow of blood to the dependent legs and feet (placed lower than the head and chest). Elevating the heels on pillows will decrease blood flow to the feet. Bending the knees with the use of the knee gatch will decrease blood flow to the feet. Elevating the foot of the bed will decrease blood flow to the feet.
Answer 33 rationale:
Hallux valgus is a painful deformity of the great toe consisting of lateral angulation towards the second toe, swelling of the bursa, and formation of a callus over the bony enlargement. The conservative treatment for hallux valgus includes wearing shoes with a wide forefoot or bunion pocket. Client A is instructed to use bunion pads to relieve pressure on the bursal sac. Hallux rigidus is the painful stiffness of the first metatarsophalangeal joint. Client B is instructed to wear a shoe with a stiff sole. Client C, with a corn, is instructed to soften the affected area with warm water and trim with a razor blade or scalpel. Client D, with pes planus, it instructed to use resilient longitudinal arch supports.
Answer 22 rationale:
Heart failure causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down. Clients with worsening heart failure will report recent weight gain because of fluid retention. Tingling in the arms is not a clinical manifestation of heart failure or poor cardiac output. Wheezing in response to dust or pollen is typical of asthma, not heart failure.
Answer 12 Rationale
Immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. The need is for an increase, not decrease, in fluid intake to compensate for that loss because of the high metabolic rate. A response to sedatives is not likely because medications are metabolized more rapidly with thyrotoxic crisis; there is a danger of exaggerated effects of the medication with hypothyroidism. Clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate.
Answer 11 Rationale
In rheumatoid arthritis, transformed autoantibodies attack synovium, producing inflammation. Urate crystals occur with gouty, not rheumatoid, arthritis. Formation of bony spurs on the joint surfaces is unrelated to rheumatoid arthritis. Deterioration and loss of articular cartilage in joints is osteoarthritis.
Answer 6 Rationale
In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Restriction of fluids may promote venous stasis and increase risk. Elevating the foot of the bed will not prevent thrombophlebitis.
Answer 31 rationale:
Inadequate oxygenation of tissues of the affected limb causes intermittent claudication (indicated by pain when exercising) and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these changes may also be associated with decreased cardiac output related to heart failure.
Answer 18 rationale:
Most breast malignancies are painless, fixed, and in the upper outer quadrant. A soft, mobile mass might indicate a lipoma. A hard, hot, painful reddened area would suggest an abscess. Multiple bilateral mobile lesions are characteristic of fibrocystic benign breast tumors.
Answer 39 rationale:
One of the several pulse points in the body is the brachial artery (option b); it is the main artery of the upper arm and it bifurcates into the radial and ulnar arteries. Option a is not a major artery of the arm; it is not a pulse point. Option c is the radial artery, which is where the radial pulse is palpated. Option d is the ulnar artery, which is where the ulnar pulse is palpated.
Answer 34 rationale:
Palpation will elicit tenderness because pressure stimulates nerve endings and causes pain. Pressure will not increase the swelling of already swollen joints. Nodules associated with rheumatoid arthritis are not caused by pressure; they occur spontaneously in about 25% of individuals with rheumatoid arthritis and are composed of collagen fibers, exudate, and cellular debris. Tophaceous deposits are present in gout, not rheumatoid arthritis; they are composed of sodium urate.
Answer 32 rationale:
Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary crackles associated with left-sided heart failure. More assessment data is needed before deciding whether fluid restrictions are needed for this client. Restricting sodium in the diet is appropriate for most clients with heart failure, but an assessment for symptoms of worsening heart failure is a higher priority. Documentation of findings is needed, but not as important as assessing the client for symptoms that may indicate a need for changes in the therapeutic plan.
Answer 37 rationale:
Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computted tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.
Answer 16 rationale:
Stair climbing increases oxygen consumption and increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension; the oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion of a meal increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.
Answer 15 rationale:
The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of ongestive heart failure in adults over 30 years old. In young, pregnant, and under 30-year-old clients, the third heart sound is often considered to be a normal parameter.
Answer 29 rationale:
The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when the arterial flow is impaired.Pink and moist ulcers are associated with venous insufficiency; arterial ulcers are pale and dry because of decreased blood flow. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency.
Answer 7 Rationale
The blood pressure (BP) in a client rises when the client's cardiac output, periphe resistance, and hematocrit are increased. Because all of these parameters are increased in client B, then that client is suspected of having hypertension. The BF falls when cardiac output is decreased. So, clients A and C may be at risk of hypotension. Client D's cardiac output may not be at risk of hypertension.
Answer 20 rationale:
The client should lie in the lateral recumbent position so the nurse may effectively detect heart murmurs (as shown in Figure 2). The supine position provides easy access to the pulse sites (shown in Figure 1). The client should be placed in the dorsal recumbent position (Figure 3) for abdominal assessment. Modified left lateral recumbent position (Figure 4) is used so the nurse may assess the rectum and vagina.
Answer 8 Rationale
The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid pulse, located along the medial edge of the sternocleidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal artery pulses are helpful in assessing the circulation to the lower leg.
Answer 1 Rationale
The response "You must feel very sick and frightened" reflects the clients feelings and encourages a further exploration of concerns. The response "Tell me why you feel you are going to die" does not reflect the feeling tone of the client's statement; also the client may not be able to answer a "why" question. The response "I can understand how you feel, but people do not die from this problem" is false reassurance; thyrotoxic crisis is capable of causing death. The response "If you would like, I will call your family and tell them to come to the hospital" may reinforce the client's anxiety and avoids discussing the clients concerns; it cuts off communication.
Answer 17 rationale:
This client is exhibiting exophthalmos, a symptom of Graves disease, which is characterized by overproduction of thyroid hormones. Because of the increased metabolic rate associated with excess thyroid hormones, the heart rate increases; the client is at risk for tachycardia, palpitations, and dysrhythmias (e.g., atrial fibrillation). Although the client probably will have an increased appetite and moist, warm skin, these physiological responses that are related to the increased metabolic rate are not life threatening. Although the client's respiratory rate will increase, the depth of respirations may or may not increase; these physiological responses are related to the increased metabolic rate and are not life threatening. Although the client will be intolerant to heat and lose weight because of the increased metabolic rate, these physiological responses are not life threatening.
Answer 2 Rationale
Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. Hypercalcemia is not helated to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands after a thyroidectomy. Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.
Answer 36 rationale:
Ulnar drift occurs when the long axis of the fingers makes an angle with the long axis of the wrist so that the fingers are deviated to the ulnar side of the hand; it is caused by changes in the metacarpophalangeal joints. Hallux valgus occurs when the great toe is angulated away from the midline of the body toward the other toes. Swan-neck deformity occurs with flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint. Boutonnière deformity occurs with fixed flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.
Answer 28 rationale:
Venous insufficiency, occurs when vascular damage impedes the body's ability to move blood from the legs toward the heart. This causes blood to pool in the legs, where it can cause swelling; pain; and, in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above the level of the heart makes use of gravitational forces to drain blood through the veins toward the heart. Clients should not wear tight restrictive pants and should avoid wearing an abdominal binder, which may impede venous return. Compression stockings prevent blood pooling. Elevating the upper extremities will not decrease edema in the lower extremities.
Answer 35 rationale:
Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema. Dry, coarse, scaly skin occurs with hypothyroidism, not hyperthyroidism, because of decreased glandular function. Smooth, warm, moist skin occurs with hyperthyroidism. Constipation is associated with hypothyroidism. Increased stools and diarrhea are associated with hyperthyroidism.
Answer 42 rationale:
With left ventricular failure, increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles, and cough. Peripheral edema occurs when ride-sided heart failure causes increases in systemic venous pressure. Jugular vein distention also occurs with right-sided failure and increased systemic venous pressure.