final exam block 3
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? -"Avoid taking daytime naps." -"Avoid hot baths and showers." -"Limit your fruit and vegetable intake." -"Restrict fluid intake to 1,500 ml/day."
"Avoid hot baths and showers."
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching? "Taking a nap after meals, when possible." "Sleeping flat without pillows is beneficial." "Eating two large meals a day, instead of three." "Eliminating bothersome foods will help."
"Eliminating bothersome foods will help."
A patient is scheduled for a test with contrast to determine kidney function. What statement made by the patient should the nurse inform the physician about prior to testing? "I don't like needles." "I am allergic to shrimp." "I take medication to help me sleep at night." "I have had a test similar to this one in the past."
"I am allergic to shrimp."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat three large meals every day without any food restrictions." "I'll eat frequent, small, bland meals that are high in fiber." "I'll lie down immediately after a meal." "I'll gradually increase the amount of heavy lifting I do."
"I'll eat frequent, small, bland meals that are high in fiber."
A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." "Instead of eating three meals a day, try eating smaller amounts more often." "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." "Drinking beverages after your meal, rather than with your meal, may bring some relief."
"Instead of eating three meals a day, try eating smaller amounts more often."
The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "It is normal to be a little confused following surgery, and it is safe not to urinate at night." "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup."
"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids."
A nursing student asks the nurse why older adults are at risk for renal disease. The best response by the nurse is: "The glomerular filtration rate decreases as we age." "Contractility of the bladder wall increases with age." "Urethral hypertrophy occurs following menopause." "Hypoplasia of the prostate occurs in older men."
"The glomerular filtration rate decreases as we age."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? -"You will have a steady and gradual decline in function." -"Your type of MS is the least common, making it difficult to manage." -"You must avoid stress and extreme fatigue, because these can trigger a relapse." -"You should take your medications only during times of relapse."
"You must avoid stress and extreme fatigue, because these can trigger a relapse."
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? "Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery." "Your small intestine will adapt over time to the absence of your appendix." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this."
"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."
When fluid intake is normal, the specific gravity of urine should be 1.000. less than 1.010. greater than 1.025. 1.010 to 1.025.
1.010 to 1.025.
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? -A disorder in which the body has too many immunoglobulins -A disorder in which histocompatible cells attack the immunoglobulins -A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" -A disorder in which the body does not have enough immunoglobulins
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 10 mL/hour A patient with a minimal urine output of 20 ml/hour A patient with a minimal urine output of 30ml/hour
A patient with a minimal urine output of 50 mL/hour
During a health history, a client explains that he was just diagnosed with Parkinson's disease and wants to know what to expect. What should the nurse include during client teaching? -Abnormal body movements such as tremors may occur at rest along with asymmetry of movement. -Eventually there will be paralysis of the extremities on one side of the body. -Whole-body convulsive movements will occur as the disease progresses. -Over time, the client's eyesight will diminish, especially at night.
Abnormal body movements such as tremors may occur at rest along with asymmetry of movement.
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal tightness Absence of peristalsis Abdominal distention Increased abdominal girth
Absence of peristalsis
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? -Acetylcholine -Epinephrine -Norepinephrine -Dopamine
Acetylcholine
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? Gastric cancer Gastric ulcer Acute gastritis Duodenal ulcer
Acute gastritis
A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first? Preparing to insert a nasogastric (NG) tube Administering I.V. fluids Obtaining a blood sample for laboratory studies Administering pain medication
Administering I.V. fluids
A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. What outcome will the decrease in erythropoietin have? Anemia from the decrease in maturation of red blood cells Increase in blood sugar levels due to alteration in insulin levels Decrease in blood sugar levels due to alteration in insulin levels Development of male sex characteristics
Anemia from the decrease in maturation of red blood cells
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? -Apply an eye patch to the right eye. -Exercise the right eye twice a day. -Administer eye drops as needed. -Place needed items on the right side.
Apply an eye patch to the right eye.
The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. Auscultate the client's apical heart rate for dysrhythmias. Assess the client's BP. Assess the client's orientation and judgment. Percuss for pain in the right lower abdominal quadrant. Assess for the presence of peripheral edema.
Assess for the presence of peripheral edema. Assess the client's BP.
Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. -Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. -Elevate the upper body on pillows. -Elevate the head of the bed on 6- to 8-inch blocks. -Avoid beer, especially in the evening. -Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid.
Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Avoid eating or drinking 2 hours before bedtime Wear tight-fitting clothing Elevate the foot of the bed on 6- to 8-inch blocks Eat a low-carbohydrate diet
Avoid eating or drinking 2 hours before bedtime
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? -Avoid hot temperatures. -Avoid physical activity. -Take moderate amounts of alcohol. -Avoid analgesic medication.
Avoid hot temperatures.
The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? Taking multivitamins as prescribed and eating organic foods whenever possible Performing 15 minutes of physical activity at least three times per week Avoid taking aspirin to treat pain or fever Maintaining a healthy body weight
Avoid taking aspirin to treat pain or fever
The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? Eliminating spicy foods. Avoiding chocolate and coffee. Eliminating cucumbers and other foods with seeds. Avoiding steamed foods.
Avoiding chocolate and coffee.
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? -Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes -Flexor spasm, clonus, and negative Babinski reflex -Blurred vision, intention tremor, and urinary hesitancy -Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Blurred vision, intention tremor, and urinary hesitancy
When describing the functions of the kidney to a client, which of the following would the nurse include? Regulation of white blood cell production Synthesis of vitamin K Control of water balance Secretion of enzymes
Control of water balance
A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate? "Liberally apply alcohol to the areas of your skin where you itch the most." "When you shower, use really warm water and an antibacterial soap." "Try washing clothes with a strong detergent to ensure that all impurities are gone." "Keep your showers brief, patting your skin dry after showering."
Correct response: "Keep your showers brief, patting your skin dry after showering."
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Distended jugular veins Crackles in the lung fields Dark, concentrated urine Cool and pale skin
Dark, concentrated urine
During hemodialysis, toxins and wastes in the blood are removed by which of the following? Filtration Ultrafiltration Osmosis Diffusion
Diffusion
The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? Azotemia Impaired immunologic response Electrolyte imbalances Diminished erythropoietin production
Diminished erythropoietin production
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Diplopia and ptosis Numbness Patchy blindness Loss of proprioception
Diplopia and ptosis
Nursing management of the client with a urinary tract infection should include: Discouraging caffeine intake Teaching the client to douche daily Instructing the client to limit fluid intake Administering morphine sulfate
Discouraging caffeine intake
Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection? Use tub baths as opposed to showers. Drink liberal amount of fluids. Drink coffee or tea to increase diuresis. Void every 4 to 6 hours.
Drink liberal amount of fluids.
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test? -Cyclosporine (Sandimmune) -Edrophonium (Tensilon) -Immunoglobulin G (Iveegam EN) -Azathioprine (Imuran)
Edrophonium (Tensilon)
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? Assess facial weakness 5 minutes after injection. Ensure atropine is readily available. Administer edrophonium chloride per orders. Document the results.
Ensure atropine is readily available.
The nurse is caring for a client who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed? -Ensure that suction apparatus is set up at the bedside. -Pad the client's bed rails. -Maintain bed rest whenever possible. -Provide several small meals each day.
Ensure that suction apparatus is set up at the bedside.
A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? Esophageal or pyloric obstruction related to scarring Chronic referred pain in the lower abdomen Gastric hyperacidity related to excessive gastrin secretion Uncontrolled proliferation of H. pylori
Esophageal or pyloric obstruction related to scarring
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Gastroesophageal reflux disease Esophageal tumor Hiatal hernia Gastritis
Esophageal tumor
Cancer of the esophagus is most often diagnosed by which of the following? X-ray Fluoroscopy Esophagogastroduodenoscopy (EGD) with biopsy and brushings Barium swallow
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? -Establish a timed voiding schedule. -Avoid foods that change the pH of urine. -Perform intermittent catheterization q6h. -Administer anticholinergic drugs as prescribed.
Establish a timed voiding schedule.
A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Adult Failure to Thrive Imbalanced Nutrition: More than body requirements Sedentary Lifestyle Excess Fluid Volume
Excess Fluid Volume
A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Sedentary Lifestyle Excess Fluid Volume Adult Failure to Thrive Imbalanced Nutrition: More than body requirements
Excess Fluid Volume
A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? Constipation related to immobility Hyperthermia related to the inflammatory process Excess fluid volume related to generalized edema Risk for injury related to altered thought processes
Excess fluid volume related to generalized edema
A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about? Gastric slowing Peptic ulcer disease Nausea Extrapyramidal
Extrapyramidal
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes Chronic obstructive pulmonary disease (COPD) Respiratory failure (RF) Congestive heart failure (CHF) Gastroesophageal reflux disease (GERD)
GERD
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastritis Peptic ulcer with melena Diverticulitis with perforation Gastroesophageal reflux disease
Gastroesophageal reflux disease
A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? Impaired Skin Integrity Related to Bowel Obstruction Ineffective Tissue Perfusion Related to Bowel Ischemia Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption Anxiety Related to Bowel Obstruction and Subsequent Hospitalization
Ineffective Tissue Perfusion Related to Bowel Ischemia
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It is a hereditary disease." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids." "It is probably your nerves."
It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin.
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. Rabeprazole (AcipHex) Famotidine (Pepcid) Nizatidine (Axid) Lansoprazole (Prevacid) Esomeprazole (Nexium)
Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)
The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's? Requip Levodopa Symmetrel Permax
Levodopa
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Assess for dehydration. Teach client behaviors that decrease urination. Limit sodium and water intake. Give medications that promote fluid retention.
Limit sodium and water intake.
The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? -MS is a progressive demyelinating disease of the nervous system. -MS usually occurs more frequently in men. -MS typically has an acute onset. -MS is sometimes caused by a bacterial infection.
MS is a progressive demyelinating disease of the nervous system.
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? -Involvement with diversion activities -Enhancement of the immune system -Establishing balanced nutrition -Maintaining a safe environment
Maintaining a safe environment
The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? -Medications must be taken on time. -Medications can be taken whenever convenient. -Medications are best taken while the client is in a reclining position. -There is no conflict with the disorder and dental work.
Medications must be taken on time.
A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? Lansoprazole Omeprazole Calcium carbonate Metoclopramide
Metoclopramide
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Esomeprazole (Nexium) Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid)
Metoclopramide (Reglan)
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? -Parkinson disease -Huntington disease -Creutzfeldt-Jakob disease -Multiple sclerosis
Multiple sclerosis
A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include? Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. Wear only nylon underwear to reduce the chance of irritation. Take medication ordered for a UTI until the symptoms subside. Limit fluid intake to reduce the need to urinate.
Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. The appendix may develop gangrene and rupture, especially in a middle-aged client. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Pain Fatigue Spasticity Aphasia Depression Numbness
Pain Fatigue Spasticity Depression Numbness
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Pancreatitis Peptic ulcer Cholecystitis Appendicitis
Pancreatitis
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? Acute pancreatitis Gastritis Peritonitis Gastroesophageal reflux
Peritonitis
A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? -Arrange for the client to receive a low residue diet. -Position the client upright during feeding. -Suction the client following each meal. -Withhold liquids until the client has finished eating.
Position the client upright during feeding.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? Chloride Sodium Potassium CO2
Potassium
A young mother with a 2 year old and a 6 month old is experiencing fatigue related to anemia. The client states that she is having difficulty performing the activities needed for her job, family, and home. With what task is it most appropriate for the nurse to assist the client? Prioritizing and balancing activities and rest. Finding a babysitter to take care of her children. Obtaining assistance from someone to help with cleaning in the home. Requesting a leave of absence from her job.
Prioritizing and balancing activities and rest.
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe? -Ptosis and diplopia -Muscle weakness and hyporeflexia of the lower extremities -Difficulty with urination -Facial distortion and pain
Ptosis and diplopia
Which of the following is the first-line therapy for myasthenia gravis (MG)? Pyridostigmine bromide (Mestinon) Deltasone (Prednisone) Azathioprine (Imuran) Lioresal (Baclofen)
Pyridostigmine bromide (Mestinon)
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? Odynophagia Dysphagia Pyrosis Dyspepsia
Pyrosis
The nurse advises the patient who has just been diagnosed with acute gastritis to: Take an emetic to rid the stomach of the irritating products. Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Restrict all food for 72 hours to rest the stomach.
Refrain from food until the GI symptoms subside.
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? -Benign -Primary progressive -Relapsing-remitting (RR) -Disabling
Relapsing-remitting (RR)
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? Facilitate a referral to the wound-ostomy-continence (WOC) nurse. Contact the physician and obtain a swab of the stoma for culture. Encourage the client to mobilize in order to enhance motility. Report signs and symptoms of obstruction to the health care provider.
Report signs and symptoms of obstruction to the health care provider.
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? Left lower quadrant Right upper quadrant Left upper quadrant Right lower quadrant
Right lower quadrant
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? Risk for Infection Related to Possible Rupture of Appendix Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake Chronic Pain Related to Appendicitis Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake
Risk for Infection Related to Possible Rupture of Appendix
Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Serum glucose pH and HCO3 Blood pressure Urine protein
Serum glucose
A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? Takes over-the-counter antacids frequently throughout the day. Smokes one pack of cigarettes daily. Reports a history of social drinking on a weekly basis. Consumes one or more protein drinks daily.
Smokes one pack of cigarettes daily.
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem? Red blood cells in the urine Sore throat 2 weeks ago Protein elevation in the urine Elevation of blood pressure
Sore throat 2 weeks ago
A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? Strategies for avoiding irritating foods and beverages Techniques for positioning correctly to promote gastric healing Safe technique for self-suctioning Strategies for maintaining an alkaline gastric environment
Strategies for avoiding irritating foods and beverages
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Streptococcal infection Menarche Hypersensitivity to an immunization Psychosocial stress
Streptococcal infection
A client who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the client's condition is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? Sudden thirst, unrelieved by oral fluid administration Diaphoresis and sudden onset of abdominal pain Tachycardia, hypotension, and tachypnea Tarry, foul-smelling stools
Tachycardia, hypotension, and tachypnea
The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? Teach the client to perform pelvic floor muscle exercises. Prepare the client for an anterior vaginal repair procedure. Provide medication teaching related to pseudoephedrine sulfate. Provide information on periurethral bulking.
Teach the client to perform pelvic floor muscle exercises.
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? -The muscles will become fatigued and the patient will not be able to chew food or swallow pills. -There should not be a problem, since the medication was only delayed by about 2 hours. -The patient will go into cardiac arrest. -The patient will require a double dose prior to lunch.
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.
Trousseau's sign.
The nurse is caring for a client who describes changes in his voiding patterns. The client states, "I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesn't seem to be much urine flow." What would the nurse expect this client's physical assessment to reveal? Urine retention Dehydration Hematuria Kidney injury
Urine retention
The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? Vitamin B12 Vitamin C Vitamin E Vitamin A
Vitamin B12
The nurse is teaching a client with recurrent urinary tract infections (UTIs) ways to decrease risk for additional UTIs. The nurse includes which information? Increase intake of coffee, tea, and colas. Void every 5 hours during the day. Void immediately after sexual intercourse. Take tub baths instead of showers.
Void immediately after sexual intercourse.
Which of the following is the most accurate indicator of fluid loss or gain? Urine output Body temperature Caloric intake Weight
Weight
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: -a positive edrophonium (Tensilon) test. -Kernig's sign. -a positive sweat chloride test. -Brudzinski's sign.
a positive edrophonium (Tensilon) test.
A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: hypotension. thick, coarse skin. deposits of adipose tissue in the trunk and dorsocervical area. weight gain in arms and legs.
deposits of adipose tissue in the trunk and dorsocervical area.
Which nerve is implicated in the Chvostek's sign? Optic Spinal accessory Facial Hypoglossal
facial
dyspepsia
indigestion
A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding? leukopenia; metabolic acidosis; elevated sodium, potassium, and chloride leukocytosis; metabolic alkalosis; elevated sodium, potassium, and chloride leukopenia, decreased hematocrit; low sodium, potassium, and chloride leukocytosis; elevated hematocrit; low sodium, potassium, and chloride SUBMIT ANSWER
leukocytosis; elevated hematocrit; low sodium, potassium, and chloride
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. sleeping in a supine position ensuring intake of food and fluids 2 to 3 hours before bedtime maintaining an upright position following meals avoiding foods that intensify symptoms
maintaining an upright position following meals avoiding foods that intensify symptoms
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with: gastroenteritis. complete bowel obstruction. paralytic ileus. Crohn's disease.
paralytic ileus.
A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? peptic ulcer disease appendicitis ulcerative colitis diverticulitis
peptic ulcer disease
Which client requires immediate nursing intervention? The client who: presents with ribbonlike stools. presents with a rigid, board-like abdomen. complains of anorexia and periumbilical pain. complains of epigastric pain after eating.
presents with a rigid, board-like abdomen.
A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: IV dextrose 50% Sorbitol sodium polystyrene sulfonate (Kayexalate) Calcium supplements
sodium polystyrene sulfonate (Kayexalate)
What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. abdominal distention sudden, sustained abdominal pain sudden drop in body temperature intermittent, severe pain
sudden, sustained abdominal pain abdominal distention
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: a decreased serum phosphate level secondary to kidney failure. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. metabolic alkalosis secondary to retention of hydrogen ions. an increased serum calcium level secondary to kidney failure.
water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
The most accurate indicator of fluid loss or gain in an acutely ill client is: pulse rate. weight. edema. blood pressure.
weight.