Exam 3

8. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night.

2.Administer corticosteroids as prescribed for inflammation.

12. Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer. 3. Esophageal cancer.

3. Esophageal cancer.

72. The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Solu-Medrol, a glucocorticoid, IV. 2. Request and obtain a STAT chest x-ray. 3. Initiate the Rapid Response Team. 4. Administer epinephrine, an adrenergic blocker, SQ then IV continuous. 5. Assess for the client's pulse and respirations.

1,3,4,5 1. Steroid medications decrease inflammation and therefore are one of the treatments for anaphylaxis. 2. A STAT chest x-ray is not indicated at this time. 3. The Rapid Response Team should be called because this client will be in res- piratory and cardiac arrest very shortly. 4. Because of its ability to activate a combination of alpha and beta recep- tors, epinephrine is the treatment of choice for anaphylactic shock. 5. The first step in initiating cardiopulmonary resuscitation is to assess for a pulse and respirations.

17. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1. "I should limit my fluids to 1 liter per day." 2. "I should use my treadmill or go for walks daily." 3. "I should follow a moderate-calcium, high-fiber diet." 4. "My alendronate helps to keep calcium from coming out of my bones."

1. "I should limit my fluids to 1 liter per day." In clients with elevated serum calcium levels, there is a risk of nephrolithiasis. One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Abdominal pain associated with bloody diarrhea. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence

1. Abdominal pain associated with bloody diarrhea.

17. The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

1. Administer 50% dextrose IVP. 17. 1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

7. The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. Assess the client's ability to read small print. Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

82. A home care nurse is assigned to visit a client who has returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instruction regarding crutch walking. On admission assessment, the nurse discovered that the client has an allergy to latex. Before providing instructions regarding crutch walking, what action should the nurse take? 1. Cover the crutch pads with cloth. 2. Contact the health care provider (HCP). 3. Call the local medical supply store and ask that a cane be delivered. 4. Tell the client that the crutches must be removed from the house immediately.

1. Cover the crutch pads with cloth. Rationale: Latex allergy is a type I hypersensitivity reaction in which a specific allergen is a processed natural latex rubber protein. The rubber pads used on crutches may contain latex. If the client requires crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact.

33. Which oral medication should the nurse question before administering to the client with peptic ulcer disease? 1. E-mycin, an antibiotic. 2. Prilosec, a proton pump inhibitor. 3. Flagyl, an antimicrobial agent. 4. Tylenol, a nonnarcotic analgesic. 1. E-mycin, an antibiotic. 33. 1. E-mycin [Erythromycin} is irritating to the stomach, and its use in a client with peptic ulcer disease should be questioned.

1. E-mycin, an antibiotic.

58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1. Eat a high-fiber diet. 2. Increase fluid intake. 4. Walk 30 minutes a day.

5. The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?

1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises. 4. Perform warmup and cool-down exercises.

25. A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

25. Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)? 1. Fever, cough, and shortness of breath. 2. Oral thrush, esophagitis, and vaginal candidiasis. 3. Abdominal pain, diarrhea, and weight loss. 4. Painless violet lesions on the face and tip of nose.

1. Fever, cough, and shortness of breath. Pneumocystis pneumonia (PCP) occurs in approximately 75% to 80% of clients diagnosed with AIDS. Signs/symptoms of it include fever, cough, and shortness of breath.

55. The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have lab work done.

1. Flush the skin with water and try to get the area to bleed. 1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse. 2. The nurse should notify the charge nurse after flushing the area and trying to get it to bleed. 3. This should be done within four (4) hours of the exposure, not before trying to rid the body of the potential infection. 4.This is done at three (3) months and six (6) months after initial exposure.

14. The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results.

1. Infuse 0.9% normal saline intravenously. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously {Fluids BEFORE REGULAR INSULIN in DKA & HHNS},

8. The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication? 1. It prevents the final transport of hydrogen ions into the gastric lumen. 2. It blocks receptors controlling hydrochloric acid secretion by the parietal cells. 3. It protects the ulcer from the destructive action of the digestive enzyme pepsin. 4. It neutralizes the hydrochloric acid secreted by the stomach.

1. It prevents the final transport of hydrogen ions into the gastric lumen.

28. The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. 5. Administer an antipyretic after the client has a spike in temperature.

1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed.

151. A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? 1. NPO (nothing by mouth) status 2. Ambulation at least 4 times daily 3. Cholinergic medications to reduce pain 4. Coughing and deep breathing every 2 hours

1. NPO (nothing by mouth) status

55. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102˚F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1. Notify the health-care provider. These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.

142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. Obtain a stool sample from the client.

40. The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.

1. Pericardial friction rub and crackles in the lungs. 1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions.

9. Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply. 1. Recommend the client not to engage in unprotected sexual activity. 2. Instruct the client not to inform past sexual partners of HIV status. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell health-care personnel of HIV status.

1. Recommend the client not to engage in unprotected sexual activity. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell health-care personnel of HIV status.

19. A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? 1. Skin rash 2. Arthralgias 3. Neurological deficits 4. Enlarged and inflamed joints

1. Skin rash The hallmark finding in stage I is a skin rash that appears within 2 to 30 days of infection. Arthralgias, neurological deficits, and enlarged and inflamed joints develop in later stages of the disease.

44. The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.

1. The client diagnosed with SLE who is complaining of chest pain. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications.

80. A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.

1. The client limits fluid intake.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use non-latex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers.

4. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2,3,5

33. The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? 1. "They activate T cells." 2. "They produce antibodies." 3. "They initiate phagocytosis." 4. "They attack and kill the target cell directly."

2. "They produce antibodies." B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis.

57. The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.

2. Administer oxygen to the client via nasal cannula. 1. Serum blood work, although ordered STAT, does not have priority over oxygenation of the client. 2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness.

The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests. 2. Complete blood count and antinuclear antibody tests.

2. Complete blood count and antinuclear antibody tests. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody.

26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? 1. Fever 2. Cough 3. Dyspnea at rest 4. Dyspnea on exertion

2. Cough The client with P. jiroveci infection (PCP) usually has a cough as the first sign. The cough begins as nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.

61. A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. 1. Falls in response to a declining viral load 2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 4. Is a direct measure of the magnitude of HIV replication 5. Guides decision making regarding timing of initiation of treatment

2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 5. Guides decision making regarding timing of initiation of treatment CD4 T-cells are a subgroup of lymphocytes that play an important role in the cell-mediated immune response; as such, CD4 T-cells are a primary marker of immunocompetence. Viral load is the direct measure of the magnitude of HIV replication. The CD4 T-cell count rises in response to a declining viral load. CD4 T-cell counts also guide decision making regarding initiation of treatment, when to change medications when treatment is failing, and the need for initiation of treatment against opportunistic infections.

31. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2. Leukocytosis with a shift to the left Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells).

17. Which assessment data should make the nurse suspect the client has chronic allergies? 1. Jaundiced sclera and jaundiced palms of hands. 2. Pale, boggy, edematous nasal mucosa. 3. Lacy white plaques on the oral mucosa. 4. Purple or blue patches on the face.

2. Pale, boggy, edematous nasal mucosa indicates chronic allergies.

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

2. Rigid, boardlike abdomen with rebound tenderness.

9. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? (SATA) 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.

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

2. The client maintains lifestyle modifications.

70. The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first? 1. The client who has a 0730 sliding-scale insulin order. 2. The client who received an initial dose of IV antibiotic at 0645. 3. The client who is having back pain at a "4" on a 1-to-10 scale. 4. The client who has dysphagia and needs to be fed.

2. The client who received an initial dose of IV antibiotic at 0645. This client has received an initial dose of antibiotic IV and should be assessed for tolerance to the medication within 30 minutes.

119. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postappendectomy and is being discharged.

2. The client who was admitted with abdominal pain who suddenly has no pain. A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, the nurse should assess this client first.

37. The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? 1. "They are produced by several types of cells." 2. "They are effective against a wide variety of viruses." 3. "They are effective against a wide variety of bacteria." 4. "They have been effective to some degree in the treatment of melanoma."

3. "They are effective against a wide variety of bacteria." Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

64. The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy.

3. Administer oxygen at 100%. 1. This intervention should be implemented, but it is not the first action. 2. This does address oxygenation but will take time to accomplish, so this interven- tion is not the first action. 3. The client is cyanotic with dyspnea and wheezing. The nurse should adminis- ter oxygen first. 4. The client may be allergic to iodine, a component of many shellfish, but the first need of the client is oxygenation.

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3. Chicken salad on whole-wheat bread and water. **avoid seeds

58. Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance.

3. Complete an advance directive. 3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

14. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 1. Creatinine level 2. Potassium concentration 3. Complete blood cell (CBC) count 4. Blood urea nitrogen (BUN) level

3. Complete blood cell (CBC) count Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Common adverse effects of zidovudine are agranulocytopenia and anemia. The nurse should monitor the CBC count for these changes

117. The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2 L/min via nasal cannula.

3. Determine the last time the client used the PCA pump.

13. The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor. 3. Dry mucous membranes.

3. Dry mucous membranes.

4. The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one (1) meal a day.

3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.

51. The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication? 1. Slow pulse; lethargy; warm, dry skin 2. Elevated pulse; lethargy; warm, dry skin 3. Elevated pulse; shakiness; cool, clammy skin 4. Slow pulse, confusion, increased urine output

3. Elevated pulse; shakiness; cool, clammy skin Signs and symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin.

68. The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach? 1. Tell the client never to scratch the rash. 2. Instruct the client in administering IM Benadryl. 3. Explain how to take a steroid dose pack. 4. Have the client wear shirts with long sleeves and high necks.3. Explain how to take a steroid dose pack.

3. Explain how to take a steroid dose pack. Clients with poison ivy are frequently prescribed a steroid dose pack. The dose pack has the steroid provided in descending doses to help prevent adrenal insufficiency.

13. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. Fever, hypotension, and polyuria 2. Hypertension, polyuria, and thirst 3. Fever, hypertension, and graft tenderness 4. Hypotension, graft tenderness, and hypothermia

3. Fever, hypertension, and graft tenderness Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection usually occurs within 3 months after transplantation, although it can occur up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately.

19. The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home? 1. Assess the client's social support network. 2. Identify the client's usual coping methods. 3. Have consistent uninterrupted time with the client. 4. Discuss and complete an advance directive.

3. Have consistent uninterrupted time with the client. Developing a therapeutic relationship with the client is priority because the client probably has less than six (6) months to live. All the other inter- ventions can be implemented, but establishing a therapeutic relationship will allow the nurse to discuss and implement additional interventions.

62. The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2. Do not use gloves when starting an IV or performing a procedure. 3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4. Wear white cotton gloves at all times to protect the hands.

3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform.

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bedrest with bathroom privileges.

3. Put client on a clear liquid diet. The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO.

39. The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of body-image changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.

3. The client will have no deterioration of organ function 3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment.

8. The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? 1. The client's Bernstein esophageal test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000/mm3. 4. The client's hemoglobin is 13.8 g/dL.

3. The client's WBC count is 14,000/mm3. The client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP.

6. The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse? 1. The client has 20 bloody stools a day. 2. The client's oral temperature is 99.8˚F. 3. The client's abdomen is hard and rigid. 4. The client complains of urinating when coughing.

3. The client's abdomen is hard and rigid. A hard, rigid abdomen indicates peritonitis, a complication of ulcerative colitis, and warrants immediate intervention.

41. The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.

3. The steroids will suppress tissue inflammation, which reduces damage to organs. The main function of steroid medications is to suppress the inflammatory response of the body.

32. The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research? 1. "It also is called inherited immunity." 2. "It is the immunity with which a person is born." 3. "It does not require previous exposure to the antigen." 4. "It includes all antigen-specific immunities a person develops during a lifetime."

4. "It includes all antigen-specific immunities a person develops during a lifetime." Rationale: Natural resistance, also called innate inherited or innate-native immunity, is the immunity with which a person is born. It does not require previous exposure to the antigen. Acquired immunity includes all antigen-specific immunities that a person develops during a lifetime.

156. The nurse is providing education to a client with type 2 diabetes mellitus. The nurse explains in layperson's language the physiological mechanism behind hypoglycemia. Which response by the client determines that teaching has been successful? 1. "My body cannot make insulin." 2. "My body has decreased epinephrine levels." 3. "My body decreases release of cortisol, which is a stress hormone." 4. "My body increases glucagon production to fight low blood sugars."

4. "My body increases glucagon production to fight low blood sugars."

23. A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? 1. Ultraviolet light therapy 2. No treatment unless symptoms develop 3. Treatment with intravenous (IV) penicillin G 4. A 14 to 21 day course of doxycycline

4. A 14 to 21 day course of doxycycline A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

53. A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication? 1. Polycythemia 2. Leukocytosis 3. Thrombocytosis 4. Agranulocytopenia

4. Agranulocytopenia Zidovudine is a neucloside-nucleotide reverse transcriptase inhibitor used to the virus. An adverse effect of this medication is agranulocytopenia with anemia. The nurse carefully monitors CBC count results for changes that could indicate this occurrence. With early infection and in the client who is asymptomatic, the CBC count is monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, the CBC count is monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The remaining options are not side or adverse effects of the medication.

104. Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Bowel assessment reveals loud, rushing bowel sounds.

20. Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? 1. Arthralgias 2. Joint enlargement 3. Erythematous rash 4. Cardiac conduction deficits

4. Cardiac conduction deficits Stage II of Lyme disease develops within 1 to 6 months in a majority of untreated persons. Arthralgias and joint enlargement are noted in stage III. A rash appears in stage I.

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

4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

12. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? 1. Monitor for signs of hyperglycemia. 2. Administer the medication without food. 3. Administer the medication with an antacid. 4. Ensure that the client uses an electric razor for shaving.

4. Ensure that the client uses an electric razor for shaving. Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.

4. Explain the need to have daily bowel movements. The client should have regular bowel movements, preferably daily. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis

18. A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? 1. Inadequate thermoregulation 2. Insufficient medication dosing 3. Toxic nervous system effects from the medication 4. Infection caused by leukopenic effects of the medication

4. Infection caused by leukopenic effects of the medication Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. Adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. The remaining options are inaccurate interpretations.

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

4. It acts topically on the colon mucosa to decrease inflammation. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.

76. Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day.

4. Provide six (6) small, well-balanced meals a day.

56. The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury. 4. Risk for injury.

4. Safety is always an issue with a client with diminished mental capacity.

75. The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse notes recent documentation of herpes simplex in the client's medical record. On assessment, the nurse would expect to note which type of lesion? 1. Macular lesions 2. Ecchymotic lesions 3. Creamy white patches 4. Vesicular lesions that rupture

4. Vesicular lesions that rupture

146. A client with type 1 diabetes mellitus is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). Which laboratory result would be expected with this diagnosis? 1. Urine is negative for ketones. 2. Serum potassium is 6.8 mEq/L (6.8 mmol/L). 3. Serum osmolality is 260 mOsm/kg (260 mmol/kg) H20. 4. Arterial blood gas values are pH 7.52, PCO2 44 mm Hg, HCO3- 30 mEq/L (30 mmol/L).

Answer: 2. Serum potassium is 6.8 mEq/L (6.8 mmol/L). Rationale: Movement of hydrogen ions from the extracellular to the intracellular fluid promotes the movement of potassium from intracellular to extracellular fluid. Thus, the serum potassium level will rise.

66. The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse should instruct the client that it is acceptable to include which item in the diet? 1. Fish 2. Cereals 3. Vegetables 4. Meat and poultry

Answer: 3. Vegetables The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. Vegetables are allowed in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals.

113. A multidisciplinary health care team is developing a plan of care for a client with hyperparathyroidism. The nurse should include which priority intervention in the plan of care? 1. Describe the use of loperamide. 2. Restrict fluids to 1000 mL per day. 3. Walk down the hall for 15 minutes 3 times a day. 4. Describe the administration of aluminum hydroxide gel.

Answer: 3. Walk down the hall for 15 minutes 3 times a day. Rationale: Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted.

106. A nurse is assigned to care for a client with type 1 diabetes mellitus. During the shift, the nurse should monitor for which manifestation as a sign of hypoglycemia? 1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps

Answer: 1. Tremors Rationale: Decreased blood glucose levels trigger autonomic nervous system signs and symptoms, such as nervousness, irritability, and tremors. Hot, dry skin accompanies hyperglycemia. Anorexia and muscle cramps are unrelated to hypoglycemia.

171. The nurse is caring for a client diagnosed with type 1 diabetes mellitus experiencing the Somogyi effect. Which blood glucose results and treatment would the nurse expect? 1. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to decrease amount of evening insulin. 2. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to increase amount of evening insulin. 3. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 240 mg/dL (13.3 mmol/L). Instruct to decrease amount of evening insulin. 4. 0300 blood glucose 190 mg/dL (10.6 mmol/L) and 0700 blood glucose 240 mg/dL (13.3 mmol/L). Instruct to increase amount of evening insulin.

Answer: 1. 0300 blood glucose 68 mg/dL (3.8 mmol/L) and 0700 blood glucose 200 mg/dL (11.1 mmol/L). Instruct to decrease amount of evening insulin. With the Somogyi effect, hyperglycemia occurs in the morning as a result of hypoglycemia during the night from too much evening insulin. Treatment includes having a bedtime snack, decreasing the amount of evening insulin, or both. Thus, option 1 is the correct answer (hypoglycemia during the night and hyperglycemia in the morning, which is treated by decreasing the evening dose of insulin).

*78. The nurse is caring for a client with a serum phosphorus level of 5.0 mg/dL (1.61 mmol/L). What other laboratory value might the nurse expect to note in the medical record? 1. Calcium level of 8 mg/dL (2.0 mmol/L) 2. Calcium level of 11.2 mg/dL (2.8 mmol/L) 3. Potassium level of 2.9 mEq/L (2.9 mmol/L) 4. Potassium level of 5.6 mEq/L (5.6 mmol/L)

Answer: 1. Calcium level of 8 mg/dL (2.0 mmol/L) Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. Therefore, if these laboratory values are altered, this suggests dysfunction of the parathyroid gland. When calcium levels are elevated (normal is 9 to 10.5 mg/dL [2.25 to 2.75 mmol/L]) and phosphorous levels are decreased (normal is 3.0 to 4.5 mg/dL [0.97 to 1.45 mmol/L]) this suggests hyperparathyroidism. If the phosphorus level is elevated, the nurse should expect the calcium level to be low.

29. The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? 1. Dark red drainage 2. Dark brown drainage 3. Green-tinged drainage 4. Light yellowish-brown drainage

Answer: 1. Dark red drainage

44. The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Thin, silky hair 3. Bulging eyeballs 4. Fine muscle tremors

Answer: 1. Dry skin Rationale: Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features; dry skin; and dry, coarse hair and eyebrows. The remaining options are noted in the client with hyperthyroidism.

167. The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1. Encourage the client to ambulate. 2. Position the client on the left side. 3. Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4. Discourage the use of the patient-controlled analgesia (PCA) machine.

Answer: 1. Encourage the client to ambulate.

8. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate

Answer: 1. Polyuria Rationale: Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia.

104. A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder? 1. Polyuria 2. Diarrhea 3. Polyphagia 4. Weight gain

Answer: 1. Polyuria Rationale: Hypercalcemia classically occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis, making polyuria the correct option. The other manifestations listed are not associated with this disorder.

49. A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? 1. Skin biopsy 2. Anti-Smith test 3. Extractable nuclear antigens 4. Anti-deoxyribonucleic acid (DNA)

Answer: 1. Skin biopsy Discoid lupus erythematosus (DLE) is one classification of lupus. Because DLE is not a systemic condition and affects only the skin; therefore, the only significant test is a skin biopsy. A microscopic evaluation of skin cell scrapings from the rash will reveal the characteristic lupus cell and a number of inflammatory cells.

*80. A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? 1. Thyroid 2. Pituitary 3. Parathyroid 4. Adrenal cortex

Answer: 1. Thyroid Rationale: The thyroid gland is responsible for a number of metabolic functions in the body. Among these are metabolism of nutrients such as fats and carbohydrates. Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. A client with increased activity of the thyroid gland will experience weight loss from the higher metabolic rate and will have an increased pulse rate.

117. The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? 1. "Do you have tremors in your hands?" 2. "Are you experiencing pain in your joints?" 3. "Do you notice swelling in your legs at night?" 4. "Have you had problems with diarrhea lately?"

Answer: 2. "Are you experiencing pain in your joints?" Rationale: Hyperparathyroidism is associated with oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and, sometimes, pathological fractures.

138. The family of a bedridden client with type 2 diabetes mellitus and chronic kidney disease calls the nurse to report symptoms of headache, polydipsia, and increased lethargy. Which most important question should the nurse ask the family to determine a possible problem? 1. "What is the client's urine output?" 2. "What is the client's capillary blood glucose level?" 3. "Has there been any change in the dietary intake?" 4. "Have you increased the amount of fluids provided?"

Answer: 2. "What is the client's capillary blood glucose level?" Rationale: Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is an acute complication of type 2 diabetes mellitus leading to hyperglycemia and dehydration. Headache, polydipsia, and increasing lethargy can be caused by the dehydration.

63. The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for a diagnostic test 4. A client with diabetes mellitus scheduled for debridement of a foot ulcer

Answer: 2. A client with Graves' disease who is having surgery Rationale: Thyrotoxicosis usually is seen in clients with Graves' disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy.

162. A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client? 1. A low-fat diet 2. A low-fiber diet 3. A high-protein diet 4. A high-carbohydrate diet

Answer: 2. A low-fiber diet Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.

116. The nurse is preparing to care for a client after parathyroidectomy. The nurse should plan for which action for this client? 1. Maintain an endotracheal tube for 24 hours. 2. Administer a continuous mist of room air or oxygen. 3. Place the client in a flat position with the head and neck immobilized. 4. Use only a rectal thermometer for temperature measurement.

Answer: 2. Administer a continuous mist of room air or oxygen. Rationale: Humidification of air or oxygen helps to liquefy mucous secretions and promotes easier breathing after parathyroidectomy. Pooling of thick mucous secretions in the trachea, bronchi, and lungs will cause respiratory obstruction.

111. A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

Answer: 2. Calcium Rationale: After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek's and Trousseau's signs. The correct treatment is administration of calcium gluconate or calcium lactate.

95. The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse should tell the client that which would be noted in a hypoglycemic reaction? 1. Thirst 2. Hunger 3. Polydipsia 4. Increased urine output

Answer: 2. Hunger Rationale: Signs and symptoms of hypoglycemia include hunger, nervousness, anxiety, dizziness, blurred vision, sweaty palms, confusion, and tingling and numbness around the mouth. Polydipsia (thirst) and increased urine output are noted in the client with hyperglycemia.

89. A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse should anticipate that which substance will be elevated? 1. Glucose 2. Ketones 3. Glucagon 4. Lactate dehydrogenase

Answer: 2. Ketones Rationale: Ketones are a byproduct of fat metabolism. When this process occurs to an extreme, the resulting condition is called ketoacidosis

59. The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? 1. Maintain a supine position. 2. Monitor neck circumference every 4 hours. 3. Maintain a pressure dressing on the operative site. 4. Encourage deep-breathing exercises and vigorous coughing exercises.

Answer: 2. Monitor neck circumference every 4 hours. After thyroidectomy, neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client should be placed in an upright position to facilitate air exchange. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. The nurse should assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

84. A client has overactivity of the thyroid gland. The nurse should expect which finding? 1. Weight gain 2. Nutritional deficiencies 3. Low blood glucose levels 4. Increased body fat stores stores.

Answer: 2. Nutritional deficiencies Rationale: Although the client may experience an increased appetite with overactivity of the thyroid gland, food intake does not meet energy demands, and nutritional deficiencies can develop. Weight loss occurs as a result of the increased metabolic activity. Glucose tolerance is decreased, and the client experiences hyperglycemia. Overactivity of the thyroid gland also causes increased metabolism, including fat metabolism. This leads to decreased levels of fat in the bloodstream, including cholesterol, and decreased body fat

55. The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I need to sit whenever possible." 2. "I need to be sure to eat a balanced diet." 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." 5. "I should engage in moderate low-impact exercise when I am not tired."

Answer: 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

117. A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? 1. Ibuprofen 2. Indomethacin 3. Acetaminophen 4. Naproxen sodium

Answer: 3. Acetaminophen Rationale: Analgesics, such as acetaminophen, are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal antiinflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they should be avoided in clients with gastritis.

7. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

Answer: 3. IV fluids containing dextrose Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia.

49. The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? 1. Draw up the correct dosage of NPH insulin into the syringe. 2. Draw up the correct dosage of regular insulin into the syringe. 3. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. 4. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.

Answer: 3. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. Rationale: The initial step in preparing an injection of insulin that is a mixture of NPH and regular insulin is to inject air into the NPH insulin bottle equal to the amount of insulin prescribed. The client would then be instructed to inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin would then be withdrawn, followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer acting form.

14. The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

Answer: 3. Irrigating the nasogastric tube

47. The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? 1. Maintain a high-carbohydrate diet. 2. Increase fluid intake, particularly at mealtime. 3. Maintain a low Fowler's position while eating. 4. Ambulate for at least 30 minutes following each meal.

Answer: 3. Maintain a low Fowler's position while eating.

143. A nurse is assisting a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) to develop a plan to prevent a recurrence. Which is most important to include in the plan of care? 1. Test urine for ketone levels. 2. Eat 6 small meals per day. 3. Monitor blood glucose levels frequently. 4. Receive appropriate follow-up health care.

Answer: 3. Monitor blood glucose levels frequently. Rationale: Client education after DKA should emphasize the need for home glucose monitoring 2 to 4 times per day. Instructing the client to notify the health care provider when illness occurs is also important. The presence of urine ketones indicates that DKA has occurred already. The client should eat well-balanced meals with snacks as prescribed.

169. The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? 1. Enteral feedings 2. Fluid restrictions 3. Oral corticosteroids 4. Activity restrictions

Answer: 3. Oral corticosteroids

140. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? 1. Hypotension 2. Bloody diarrhea 3. Rebound tenderness 4. A hemoglobin level of 12 mg/dL (120 mmol/L)

Answer: 3. Rebound tenderness

68. The nurse is caring for a client admitted to the hospital with uncontrolled type 1 diabetes mellitus. In the event that diabetic ketoacidosis (DKA) does occur, the nurse anticipates that which medication would most likely be prescribed? 1. Glucagon 2. Glyburide 3. Regular insulin 4. Neutral protamine Hagedorn (NPH) insulin

Answer: 3. Regular insulin Rationale: Giving regular insulin by the intravenous route is the treatment of choice for DKA. A short-acting insulin is the only insulin that can be given intravenously because it can be titrated to the client's blood glucose levels.

64. The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1. "I need to eat foods high in potassium." 2. "I need to drink at least 2 to 3 L of fluid daily." 3. "I need to eat small, frequent meals and snacks if nauseated." 4. "I need to increase my intake of dietary items that are high in calcium."

Answer: 4. "I need to increase my intake of dietary items that are high in calcium." The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption of calcium. Dietary restriction of calcium may be used as a component of therapy.

78. The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction? 1. "I need to eat foods that are liquid or pureed." 2. "I need to eliminate spicy foods from my diet." 3. "I need to eliminate citrus juices and hot liquids from my diet." 4. "I need to rinse my mouth 4 times daily with a commercial mouthwash."

Answer: 4. "I need to rinse my mouth 4 times daily with a commercial mouthwash."

149. A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? 1. "I know I can massage my abdomen." 2. "I will continue using antispasmodic medication." 3. "One of the best things I can do is use relaxation techniques." 4. "The best position for me is to lie supine with my legs straight."

Answer: 4. "The best position for me is to lie supine with my legs straight."

50. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? 1. A decreased-calorie diet 2. An increased-calorie diet 3. A decreased amount of NPH insulin daily insulin 4. An increased amount of NPH insulin daily insulin

Answer: 4. An increased amount of NPH insulin daily insulin Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection is present, an increase in the dose of insulin will be required to facilitate the transport of excess glucose into the cells.

93. The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder? 1. Serum pH of 9.0 2. Absent ketones in the urine 3. Serum bicarbonate of 22 mEq/L (22 mmol/L) 4. Blood glucose level of 500 mg/dL (28.5 mmol/L)

Answer: 4. Blood glucose level of 500 mg/dL (28.5 mmol/L) Rationale: In the client with DKA, the nurse should expect to note blood glucose levels between 350 and 1500 mg/dL (20 and 85.7 mmol/L), ketonuria, serum pH less than 7.35, and serum bicarbonate less than 15 mEq/L (15 mmol/L).

96. A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

Answer: 4. Hyperosmolar hyperglycemic syndrome (HHS) Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness.

139. A client with type 2 diabetes mellitus is complaining of polydipsia, polyuria, weight loss, and weakness. Laboratory results indicate a blood glucose level of 800 mg/dL (45.7 mmol/L) and nonketosis. The nurse reviews the health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

Answer: 4. Hyperosmolar hyperglycemic syndrome (HHS) Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. In HHS, the client is nonketotic.

101. A client has begun medication therapy with propylthiouracil. The nurse should assess the client for which condition as an adverse effect of this medication? 1. Joint pain 2. Renal toxicity 3. Hyperglycemia 4. Hypothyroidism

Answer: 4. Hypothyroidism Rationale: Propylthiouracil is prescribed for the treatment of hyperthyroidism. Excessive dosing with this agent may convert a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required to treat the hypothyroid state.

35. A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? 1. Glyburide via the oral route 2. Glucagon via the subcutaneous route 3. Insulin aspart via the subcutaneous route 4. Regular insulin via the intravenous (IV) route

Answer: 4. Regular insulin via the intravenous (IV) route Rationale: The client is most likely in diabetic ketoacidosis (DKA). Regular insulin via the IV route is the preferred treatment for DKA. Regular insulin is a short-acting insulin and can be given intravenously; it is titrated to the client's high blood glucose levels.

155. During health history taking, the client complains of weight loss and diarrhea and says that he can "feel my heart beating in my chest." The nurse anticipates that which diagnostic test will most likely be prescribed by the health care provider (HCP) in order to determine the underlying condition leading to the client's signs and symptoms? 1. Endoscopy 2. Electrocardiogram 3. Stool for occult blood 4. Serum thyroid-stimulating hormone (TSH)

Answer: 4. Serum thyroid-stimulating hormone (TSH) A client with increased activity of the thyroid gland exhibits weight loss as a result of the higher metabolic rate, increased frequency of bowel movements or diarrhea, and an increased pulse rate, which account for the client's complaint of feeling his heart beating in his chest. Therefore, a TSH level should be drawn to validate hyperthyroidism. The TSH level will be decreased in hyperthyroid states.

167. The nurse caring for a male client newly admitted to the hospital with a diagnosis of pneumonia suspects that the client is also at risk for metabolic syndrome if which characteristics have been identified in this client? Select all that apply. 1. Hemoglobin A1C of 6.5% 2. Waist circumference of 36 inches 3. Triglycerides 160 mg/dL (1.81 mmol/L) 4. Consistent systolic blood pressures <130 mm Hg 5. Serial fasting glucose levels of 120 mg/dL (6.85 mmol/L), 132 mg/dL (7.54 mmol/L), and 128 mg/dL (7.31 mmol/L)

Answers: 1. Hemoglobin A1C of 6.5% 3. Triglycerides 160 mg/dL (1.81 mmol/L) 5. Serial fasting glucose levels of 120 mg/dL (6.85 mmol/L), 132 mg/dL (7.54 mmol/L), and 128 mg/dL (7.31 mmol/L) Rationale: Features of metabolic syndrome include abdominal obesity: waist circumference of 40 inches (100 cm) or more for men; hyperglycemia: fasting blood glucose level of 110 mg/dL (6 mmol/L) or more or on medication treatment for elevated glucose; abnormal hemoglobin A1C: >6.0%; hypertension: systolic blood pressure of 130 mm Hg or more or diastolic blood pressure of 85 mm Hg or more or on medication treatment for hypertension; hyperlipidemia: triglyceride level of 160 mg/dL or more or on medication treatment for elevated triglycerides, normal triglyderides is 40 to 160 mg/dL (0.45 to 1.81 mmol/L); high-density lipoprotein cholesterol less than 40 mg/dL for men: normal is >40 mg/dL (>1.55 mmol/L).

152. The nurse is caring for a client with a diagnosis of diabetic ketoacidosis (DKA). Which assessment findings are consistent with this diagnosis? (SATA) 1. Polyuria 2. Polydipsia 3. Polyphagia 4. Dry mouth 5. Flushed, dry skin 6. Moist mucous membranes

Answers: 1. Polyuria 2. Polydipsia 3. Polyphagia 4. Dry mouth 5. Flushed, dry skin Rationale: Clinical manifestations of DKA include polyuria (frequent urination); polydipsia (excessive thirst); polyphagia (excessive hunger); dry mouth; and flushed, dry skin. The client with DKA experiences dehydration.

16. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

Answers: 1. Polyuria 3. Bone pain The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain.

19. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.' 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

Answers: 1. Tremors 3. Irritability 4. Nervousness Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors.

88. The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. 1. Irritability 2. Periorbital edema 3. Coarse, brittle hair 4. Slow or slurred speech 5. Abdominal distention 6. Soft, silky, thinning hair

Answers: 2. Periorbital edema 3. Coarse, brittle hair 4. Slow or slurred speech 5. Abdominal distention

31. The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. 1. Provide a warm environment for the client. 2. Instruct the client to consume a low-fat diet. 3. A thyroid-releasing inhibitor will be prescribed. 4. Encourage the client to consume a well-balanced diet. 5. Instruct the client that thyroid replacement therapy will be needed. 6. Instruct the client that episodes of chest pain are expected to occur.

Answers: 3. A thyroid-releasing inhibitor will be prescribed. 4. Encourage the client to consume a well-balanced diet.

*23. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

Answers: 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

27. The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

Answers: 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? A) Diagnosis of AIDS is made when you have 2 positive ELISA test results. B) Diagnosis is made when both the ELISA and the Western Blot tests are positive. C) I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister? D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.

D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.

A diagnosis of AIDS can be made for a patient with HIV with: a: a CD4+ T-cell count <500/ul b. a WBC count <300/ul c. development of oral candidassis d. onset of pneumocystis jroveci pneumonia

d. onset of pneumocystis jroveci pneumonia The Centers for Disease Control (CDC) has established criteria for a patient to be diagnosed with AIDS. AIDS is diagnosed when an HIV-positive individual develops at least one of several criteria: examples are CD4+ T-cell count less than 200 cells/uL and fungal infection such as Pneumocystis jiroveci pneumonia (PCP). Candidiasis infection must be of the bronchi, trachea, lungs, or esophagus (not only the mouth).