Illness 2 Exam 2
After assessing a client with ALS, the nurse finds that the oral communication of the client is impaired. Which should the nurse document in the client's medical record? A. Dysarthria B. Motor neuron death C. Muscle weakness D. Respiratory weakness
A
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalance should the nurse expect? a. hyperkalemia b. hypernatremia c. hypercapnia d. hypophosphatemia
A
A young child has just been diagnosed with pseudohypertophic (Duchenne) muscular dystrophy. An aspect of care should include which of the following? a. recommend genetic counseling b. explain that the disease is easily treated c. suggest ways to limit use of muscles d. assist family in finding a nursing facility to provide his care
A
A 12 year-old with GBS is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, the priority asssessment includes: a. swallowing ability b. parental involvement c. level of consciousness d. antecedent viral infections
A
A nurse in the emergency department is caring for a client who has extensive partial full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid balance D. Paralytic ileus
A
A nurse is assessing the MRI results of four clients with renal trauma. Which client requires priority treatment? A. Client with a thrombus in the renal artery or vein B. Client with nonexpanding hematoma and superficial lacerations C. Client with injuries pf the renal artery or vein with controlled hemorrhage D. Client with lacerations 1.2 cm deep but not involving the collecting system
A
A nurse is caring for a newborn who has a myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? a. maintain the integrity of the sac b. promote maternal-infant bonding c. educate the parents about the defect d. provide age-appropriate stimulation
A
After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A. I will limit my total intake of fluids B. I must avoid drinking alcoholic beverages C. I must avoid drinking caffeinated beverages D. I shall try to lose about 10% of my body weight
A
An RN is teaching nursing students about the postoperative monitoring of a client who has undergone a transphenoidal hypophysectomy. Which statement of a nursing student indicated the need for further teaching? a. I will monitor the client for hypovolemic shock b. I will monitor the client for cerebrospinal leakage c. I will monitor the client for increased intracranial pressure d. I will monitor the client for diabetes insipidus
A
Anticholinergics are used to reduce tremors and drooling associated with Parkinson's disease (PD). Which side effect of this drug contraindicates it for older clients? A. Memory impairment B. Urinary frequency C. Nausea and vomiting D. Disorders of impulse control
A
The nurse is assessing a patient who has a family history of type 2 diabetes. Which of these findings if identified in this patient would require follow-up by the nurse? A. The patient has a new prescription for levothyroxine (Synthroid) for hypothyroidism B. The patient has decreased his waist-to-hip ratio through dietary changes C. The patient has delivered a baby that weighed 8 lbs 12 oz D. The patient has a fasting blood glucose level of 100 mg/dL
A
The nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take? A. Teach the patents about cortisol replacement therapy B. Place the child on a low- sodium diet C. Monitor the child for fluid volume excess D. Discuss the manifestations of hypoglycemia with the parents
A
The nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? A. Check the results of the client's most recent CBC B. Assess the client for a hypersensitivity reaction C. Evaluate the client for hypercalcemia D. Examine the client for hepatomegaly
A
The nurse is caring for a client with hypopituitarism from a lack of adrenocorticotropic hormone (ACTH). Which complication is most likely to occur in this client? A. Circulatory collapse B. Osteoporosis C. Water retention D. Cervical contractions
A
The nurse is caring for the patient at risk for increase ICO. Which sign is most likely to be the first indication of increased ICP? A. Decline of LOC B. Increase systolic BP C. Change in pupil size and response D. Abnormal posturing of extremities
A
The nurse is reviewing the biographic data and history for the patient with myasthenia graves. What does the nurse expect to see included in the patient's records? A. Muscle weakness that increases with exertion or as the day wears on B. Difficulty sleeping with early morning walking and restlessness C. Confusion and disorientation in the late afternoon D. Muscle pain and cramps that interfere with activities of daily living
A
The patient is diagnosed with trigeminal neuralgia. Which therapy is the first-line choice for this patient? A. Antiepileptic such as gabapentin (Neurontin) B. Muscle relaxant such as baclofen (Lioseral) C. Percutaneous steriotactic rhizotomy D. Microvascular decompression
A
What is the priority diagnosis for atonic seizures? A. Risk of injury r/t falls B. Ineffective tissue perfusion r/t neuromuscular dysfunction C. Acute confusion r/t postictal state D. Activity intolerance r/t a-tonicity of muscles
A
Which assessment finding corresponds with the first stage of Parkinson's Disease? A. Upper extremity tremors B. Muscle rigidity C. Shuffling gait D. Postural instability
A
Which assessments should be performed to prevent infrarenal damage form post-renal causes in clients with acute kidney injuries? A. Examination of prostate B. Measurement of blood volume C. Measurement of cardiac output D. Identification of nephrotoxins
A
Which clinical manifestations is associated with diabetes insidious is a client? A. Heart rate is increased B. Pulse is full and bounding C. Blood pressure is increased D. Serum osmolarity is decreased
A
Which condition leads to panhypopituitarism? A. Reduced secretion of all hormones from the hypothalamus B. Reduced secretion of a hormone from the anterior pituitary gland C. Reduced secretion of a hormone from the hypothalamus D. Reduced secretion of thyroid hormones
A
Which drug is most likely to be administered to a client with pheochromocytoma who develops an intra-operative hypertensive episode? A. Nitroprusside B. Kayexalate C. Pasireotide D. Dexamethasone
A
Which of the following indicates that the client with diabetes insidious understands how to manage care? A. The client will maintain normal fluid and electrode balance B. The client will select American Diabetes Association diet correctly C. The client will state dietary restrictions D. The client will exhibit serum glucose level within normal range
A
Which of the following should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? A. Emphasizing that the client will need steroid replacement for the rest of her life B. Instructing the client about the importance of tapering steroid medication carefully to prevent crisis C. Informing the client that steroids will be required only until her body can manufacture sufficient quantities D. Emphasizing that the client will need to take steroids whenever he life involves physical or emotional stress
A
The nurse is assessing an 8 month-old for cerebral palsy. Which of the following findings is a manifestation of the condition? a. tracks an object with eyes b. sits with pillow props c. smiles when a parent appears d. uses a pincer grasp to pick up a toy
B
A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? Select all the apply. A. Loss of color discrimination B. Coarse facial features C. Enlarged distal extremities D. Hepatomegaly E. Moon face
A, B, C, D
The patient with increase ICP is to receive IV mannitol in the acute unit. Which nursing actions are instituted with the administration of this drug? select all that apply a. draw up the drug through a filtered needle b. insert a Foley catheter to measure strict urine output c. monitor serum osmolality on a weekly basis d. assess for acute renal failure, weakness or edema e. administer mannitol through a filter in the IV tubing
A, B, D, E
A nurse is caring for a client who has undergone surgery for a spinal tumor. Which complications are most commonly seen in clients after this type of surgery? Select all that apply. A. Meningitis B. Sexual dysfunction C. Loss of bowel or bladder function D. Decreased sensitivity to pain, head or cold E. Hematoma
A, B, E
Which interventions should the nurse implement when caring for the client who has undergone a transsphenoidal hypophysectomy? Select all that apply. A. Conduct neurological assessment B. Maintain the head of the bed flat C. Provide frequent mouth care D. Monitor the nasal drainage pad E. Obtain urine specific gravity every 8 hours
A, C, D
Which is true regarding hyperpituitarism? Select all that apply. A. It is the result of hypersecretion of hormones from the anterior pituitary gland B. It is controlled with hormone replacement therapy C. It is often related to a hypersecreting tumor D. It may lead to headaches and visual changes E. It is found to have a genetic association
A, C, D, E
The symptoms of a pheochromocytoma include all of the following? a. widening pulse pressure b. bradycardia c. increased systolic BP d. decreased stroke volume e. increased cardiac output f. tremors
A, C, E, F
An RN is teaching nursing students on the preoperative management of a client with a pheochromocytoma. Which statement made by a nursing student indicates the need for further teaching? select all that apply a. I will put the client on bed rest in the supine position b. I will place the client son a cardiac monitor to assess for cardiac dysrhythmias c. I will administer a smooth muscle relaxant d. I will monitor the client for hypotensive crisis e. I will monitor the client for hemorrhage
A, D, E
The nurse is caring for a healthy patient who has a serum glucose levels of 60 mg/dl. The nurse anticipates which of the following counter-regulatory serum hormonal changes are likely to occur in this patient? select all that apply a. increased epinephrine levels b. decreased glucocorticoid levels c. increased insulin levels d. decreased thyroxine levels e. increased growth hormone levels
A, E
Which interventions should the nurse implement for the client with Parkinson's disease? Select all that apply a. elevate HOB when eating and drinking b. arrange speech therapy for the client c. teach the client to take long steps while walking d. teach the client to call the healthcare provider for medical compliance e. discuss and evaluate the client's ability to move
A,B, D, E
A 57 year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician? a. urine output of 350 mL in 8 hours b. urine specific gravity of 1.001 c. potassium of 4.0 mEq/L d. weight gain
B
A client involved in an auto accident has severe spinal cord injuries. If the client is having difficulty with diaphragmatic breathing, which level of the spinal cord is injured? A. C1 to C4 B. C6 to C7 C. T1 to T12 D. Below L1
B
A client is diagnosed with inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluids and electrolyte balances? a. increased osmolality of the plasma b. decreased serum sodium level c. increased urine output d. decreased blood pressure
B
A client sustained an accident and was brought immediately to the hospital. The imaging results show nearly 1.5 cm deep renal lacerations that do not involve the collecting system. Which grading of renal trauma would be given to the client? A. Grade 2 B. Grade 3 C. Grade 4 D. Grade 5
B
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? A. Polyuria B. Facial edema C. smokey brow urine D. Hypertension
B
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor? a. hypermagnesemia b. hypokalemia c. hyperkalemia d. hypomagnesemia
B
A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching? A. Limit intake of potassium-rich foods B. Restrict sodium intake C. Increase carbohydrate intake D. Decrease protein intake
B
A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 DM. Which of the following instructions should the nurse include in the teaching? A. Test your blood glucose level every 8 hours B. Check your urine for ketones when blood glucose levels are greater than 240 mg/dL C. Withhold your usual daily dose of insulin D. Drink 240-360 mL of calorie-free liquids every 8 hours
B
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following condition can increase the risk of renal calculi a. protein in the urine b. dehydration c. iron deficiency d. obesity
B
Desmopressin is administered to the client with diabetes insipidus because it A. Decreases BP B. Increased tubular reabsorption of water C. Increases release of insulin from the pancreas D. Decreases glucose production within the liver
B
In planning care for the patient with increased ICP, what does the nurse do to minimize ICP? A. Gives the bath, changes the linens and does passive ROM exercises to hand/fingers and then allows the patient to rest B. Give the bath, allows the patient to rest, changes the linens, allows the patient to rest, and then performs passive ROM exercises to hands/fingers C. Defers the bath, changes the linens and does passive ROM exercises to extremities until the danger of increased ICP has passed D. Contacts the physician for specific orders about all activities related to the care of the patient that may cause increased ICP
B
The client with pheochromocytoma is scheduled for surgical resection of the tumor in the adrenal medulla. The nurse should monitor the client postoperatively for which of the following potential complications? A. Bradycardia B. Hemorrhage C. Hypoglycemia D. Hyponatremia
B
The clinical manifestations of encephalitis are the same as those of meningitis. Which characteristic feature helps identify encephalitis? A. It involves pathogens that invade the CNS B. It involves the cerebrum, brainstem, and cerebellum C. It can be life-threatening emergency leading to increased cranial pressure, coma, and death D. It is diagnosed by examining the cerebrospinal fluid
B
The nurse is caring for a client status post bilateral adrenalectomy who is receiving glucocorticoids and mineralocorticoids. The nurse will monitor for which of the following? a. postoperative confusion b. delayed wound healing c. emboli d. malnutrition
B
The nurse is caring for a patient with type 1 diabetes mellitus. The patient reports feeling a sensation of nausea and states that he has had one episode of vomiting in the past 2 hours. The patient states that he does believe he should take the scheduled morning insulin based on his symptoms. What action by the nurse is best at this time? A. Contact the physician B. Explain the need to take the insulin C. Document the refusal and continue on with the planned care D. Check the patient's fasting serum glucose level
B
The nurse is caring for the patient with risk for impaired swallowing. Which intervention foes the nurse employ for this patient? A. Limit the diet to clear liquids B. Give a small spoonful of custard C. Give tiny bits of finely cut-up chicken D. Chat with the patient while the patient eats
B
The nurse is providing teaching to a group of patients who are planning to participate in an athletic triathlon. Each member of the group has been diagnosed with either DM 1 or 2. A member of the group asks "If we each follow our usual daily diabetic control routine, which diabetic complication is most likely to occur during this athletic event?" The nurse's best answer is which of the following? A. DKA B. Hypoglycemia C. HHS D. Impaired glucose tolerance
B
The nurse should monitor the client with Cushing's disease fr which of the following? A. Postprandial hypoglycemia B. Hypokalemia C. Hyponatremia D. Decreased urine calcium level
B
The patient arrive in the ED reporting headache, fever, nausea, and photosensitivity. Which diagnostic test does the nurse anticipate the physician will order to rule out meningitis? A. X-ray of the skull B. Lumbar puncture C. Myelography D. Cerebral angiogram
B
The patient has had an infratentorial craniotomy. Which position does the nurse utilize for this patient? A. High-fowler's position; turned tot he operative side B. Head of bed at 30 degrees, turned to the nonoperative side C. Flat in bed, turned to the operative side D. Flat in bed, may turn to either side
B
The patient is at risk for increased ICP and is receiving oxygen at 2L NC. The nurse is reviewing the ABG results. Which ABG value is of greatest concern for this patient? A. pH= 7.34 B. PaCO2= 49 mmHg C. PaO2= 95 mmHg D. HCO3= 28 mEq/L
B
The patients with Guillian-Barre syndrome (GBS) describes a chronologic progression of motor weakness that started in the legs and then spread to the arms and the upper body. Which type of GBS do these symptoms indicate? a. pure motor b. ascending c. descending d. Miller Fisher variant
B
The preferred administration time for recombinant tissue plasminogen activator (rT-PA) is within how long of a stroke symptoms onset? A. 45 mins B. 3 hours C. 6 hours D. 24 hours
B
What is the duration of the oliguric phase in acute kidney injury? A. Hours to days B. Up to 14 days or longer C. 1-3 weeks D. Several months to one year
B
Which best describes the differentiation between central diabetes insidious and nephrogenic diabetes insidious? A. It occurs because the kidneys are resistant to antidiuretic hormone (ADH) B. It is caused by a decreased secretion of antidiuretic hormone (ADH) C. It is observed in clients with chronic insufficiency D. It occurs when the kidneys are unable to concentrate urine
B
Which is associated with decreased mineralocorticoids die to hypopituitarism? a. hypoglycemia b. hyponatremia c. decreased cortisol levels d. decreased ability to handle stress
B
Which is true regarding the antimuscarinic class of medication that treats multiple sclerosis? a. it helps that large intestine to absorb water, increasing the bulk of stool b. it reduces bladder spasms by inhibiting acetylcholine c. it inhibits transmission of impulses through parasympathetic nerve fibers d. it mimics the effects of hormones produces in the adrenal glands
B
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus? a. taking vital signs every 2 hours b. measuring urine output hourly c. assessing arterial blood gas values every other day d. checking blood glucose levels
B
Which of the following is the priority for a client with Addison's crisis? A. Controlling hypertension B. Preventing irreversible shock C. Preventing infection D. Relieving anxiety
B
Which of the following would be an expected finding in a client with adrenal crisis or Addisonian crisis)? A. Fluid retention B. Pain C. Peripheral edema D. Hunger
B
Which statement about the pituitary gland is correct? a. the main role of the posterior pituitary is to secrete tropic hormone b. the posterior pituitary gland stores hormones produced by the hypothalamus c. the anterior pituitary is connected to the thalamus d. the anterior pituitary is connected to the thalamus gland e. the anterior pituitary releases stored hormones produced b the hypothalamus
B
Which are clinical manifestations of ALS? select all that apply. A. Double or blurred vision B. Difficulty swallowing C. Fasciculation D. Tremor E. Memory loss
B, C
Which is the most appropriate for the nurse to assess when caring for a client diagnoses with hyperpituitarism due to increased secretion of adrenocorticotropic hormone (ACTH)? Select all the apply. A. Pain caused by compression of peripheral nerves B. Neurological assessment and vision C. Urine intake and output D. Daily weight E. Changes in the size of the hands
B, C, D
The neurologist orders 500 mg methylprednisolone (Solu-Medrol) IV daily. What do you need to do to administer this medication safely? select all that apply a. reconstitute with 9 ml of benzyl alcohol b. administer a total dose of 8 ml of reconstituted solution c. use the solution within 60 minutes of reconstitution d. begin the medication infusion before 0900 each day e. deliver the dose over 30 minutes using IV pulse administration
B, D
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? Select all that apply. A. Polyuria B. Blurred vision C. Polydipsia D. Tachycardia E. Moist, clammy skin
B, D, E
The RN is teaching nursing students about monitoring for clinical manifestations when assessing spinal shock in a client. Which statement made by the nursing students indicates effective teaching? Select all that apply. A. "The client would have low urine output." B "The client would have improper digestion." C. "The client would have low blood pressure." D. "The client would have a decreased heart rate." E. "The client would not show reflexes if tapped on the knee."
B, E
A client is admitted with pheochromocytoma. The nurse assesses the client's BP frequently because pheochromocytoma of the adrenal medulla releases excessive amounts of A. Renin B. Aldosterone C. Catecholamines D. Glucocorticoids
C
A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with deficient fluid volume related to inadequate intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate? a. milk and diet sod b. water and eggnog c. bouillon and juice d. coffee and milkshakes
C
A client with SIADH is hospitalized. Which clinical manifestation is most likely to be seen in this client? A. Thirst is increased B. Pulse is weak and accelerated C. BUN is decreased D. Urine specific gravity is decreased
C
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? a. stress incontinence b. urger incontinence c. overflow incontinence d. reflex incontinence
C
A nurse is assessing a 3-year-old for hemolytic uremic syndrome (HUS). Which assessment finding would be most characteristic of HUS? A. Decreased creatinine B. Elevated pH C. Oliguria D. Decreased respiratory rate
C
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? a. Kernig's signs b. nuchal rigidity c. Brudzinskis sign d. bradykinesia
C
A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective? A. Perform ROM on the infant's hip B. Maintains a dry dressing over the sac C. Takes an axillary temperature D. Places the infection in a side-lying position
C
A patient diagnosed with type 2 diabetes s admitted to the ICU with HHNK. Which assessment data should the nurse expect the client to exhibit? a. Kussmaul's respirations b. diarrhea and epigastric pain c. dy mucous membranes d. ketone breath odor
C
During shift report the nurse hears that the patient with GBS has a decrease in vital capacity that is less that 2/3 of normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient? A. Frequent oral suctioning B. Rigorous chest physiotherapy C. Elective intubation D. Elective tracheostomy
C
Spastic cereal palsy (CP) is characterized by which of the following? A. Athetosis, dystonic movements B. Tremors, lack of active movement C. Hypertonicity; poor control of posture, balance, and coordinated motion D. Wide-based gait; poor performance of rapid, repetitive movements
C
The nurse assesses a client who has a hemisection of the spinal cord resulting from a gunshot injury. The client has lost motor functions, proprioception, and vibration on the injured side. Which kind of incomplete injury of the client can the nurse identify from the scenario? A. Central cord syndrome B. Anterior cord syndrome C. Brown- Séquard syndrome D. Posterior cord syndrome
C
The nurse is caring for a client with acute kidney injury who has a serum potassium level of 5.5 mmol/L. The nurse administers sodium polystyrene sulfonate to the client. What is the rationale behind this nursing action? a. to stabilize the myocardial cell membrane b. to facilitate the elimination of potassium in urine c. to enhance the total body elimination of potassium d. to facilitate the intracellular movement of potassium
C
The nurse is caring for the patient who was admitted for a diagnosis of meningococcal meningitis. Which nursing action is specific to this type of meningitis? a. administer an antifungal agent such as amphotericin B b. observe the patient for genital lesions c. place the patient in isolation per hospital procedure d. check to see if the patient is HIV positive
C
The patients has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasopasm? a. phenytoin b. dexamthasone c. nimodipine d. clopidogrel
C
What clinical manifestation correlates with SIADH? A. Fever B. Polyuria C. Confusion D. Increased appetite
C
When planning D.V.'s care, what is the most appropriate goal for the clinical problem of activity intolerance related to muscle weakness? A. "D.V. will maintain muscle strength in his arms and legs" B. "D.V. can identify 3 factors that aggravate muscle weakness" C. "D.V. will participate in daily activities as desired without fatigue" D. "D.V. is free of trauma related to muscle weakness"
C
Which finding helps the nurse to distinguish syndrome of inappropriate antidiuretic hormone (SIADH) from another case in which the client presents with scant, concentrated urine? a. the client appears dehydrated b. the serum sodium level is increased c. the serum osmolarity is decreased d. the specific gravity of the urine is increased
C
Which is a common complication of amyotrophic lateral sclerosis (ALS)? a. seizures b. paralysis c. pneumonia d. muscle spasm
C
Which of the following statements best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)? A. It has an autosomal dominant inheritance pattern B. Onset occurs in later childhood and adolescence C. It is characterized by presence of Gower sign, waddling gait, and lordosis D. Disease stabilizes during adolescence, allowing for life expectancy to approx. are 40
C
Which test involves a dye to be injected in the spinal column and x-ray images taken of it? a. computed tomography b. electromyography c. myelogram d. nerve conduction studies
C
The patient is admitted for probable diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which test does the nurse anticipate will be ordered for this patient? A. Electroencephalography (EEG) B. Cerebral blood flow (CBF) C. Electrocardiogram (ECG) D. Electromyography (EMG)
D
The nursing student is caring for the patient with partial seizures. Which statement by the student indicates an understanding of partial seizures? A. "The patient should be placed in a vest when sitting in a chair." B. "There is no medical treatment for partial seizures." C. "I should have a padded tongue blade at the bedside." D. "The patient may repeatedly pick at the linens."
D
A home health nurse is caring for an elderly client with Alzheimer's disease. Which intervention should the nurse implement for the client? a. provide the client with semi-soft diet b. encourage the client to take an afternoon nap c. provide the client with a different schedule everyday d. speak calmly using positive statements
D
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care? A. Provide respite services for the parents B. Improve the client's communication skills C. Foster self- care activities D. Modify the environment
D
A nurse in an emergency department is caring for a client who has DKA and a blood glucose of 925. The nurse should anticipate which of the following prescriptions for the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45 NS C. Oral hypoglycemic medications D. ).9% NS IV bolus
D
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. the nurse should recognize which of the following conditions can cause incontinence in the older adult client? a. nephrosclerosis b. uremia c. diverticulitis d. cystitis
D
A nurse is assessing the clinical manifestation of four clients. Which of the following client is most likely to have renal trauma Client A: edema of lower extremities, abdominal pain Client B: nocturia, fever, and chills Client C: flank mass, hypertension, weight loss Client D: hypotension, flank bruising, gross hematuria a. client A b. client B c. client C d. client D
D
A nurse is carrying for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Delay in disease progression B. Improved bladder function C. Relief of depression D. Decreased tremor
D
A nurse is discussing lab values associated with the renal system with a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding go the values? A. Potassium levels are increased in clients who have polyuria B. Specific gravity is decreased in clients who have hypovolemia C. BUN is decreased in clients who have dehydration D. Creatinine levels are increased in clients who have acute kidney injury
D
A nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations> a. completing the spring semester of school b. gaining 4 pounds c. becoming engaged d. undergoing a root canal
D
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? A. Apply cold compress to the client's flank area B. Restrict protein intake to 2 servings per day C. Discourage ambulation D. Encourage intake of at least 3 L of fluids per day
D
A patient diagnosed with an adrenal gland deficiency tells the nurse, "I am rarely outside in the sun and I'm getting such a tan!" Which of the following nursing interventions is a priority in addressing the patient's concern? A. Palpate the patient's thyroid B. Ask the patient what time pf day he or she is outdoors C. Auscultate the patient's lung sounds D. Ask if the patient is still taking the prescribed steroid
D
The major goal of therapy for children with cerebral palsy include which of the following? A. Cure underlying defects causing the disorder B. Reverse degenerative processed that have occurred C. Prevent spread to individuals in close contact with child D. Recognize the disorder early and promote optimum development
D
The nurse is carefully monitoring the patient with a severe case of encephalitis for signs of increased ICP. What vital sign changes are associated with increased ICP? A. Tachycardia and shallow, rapid respiration's B. Increased core temp and bradycardia C. Decreased pulse pressure and tachypnea D. Widened pulse pressure and bradycardia
D
The nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching? A. "I can expect to have swelling in my face." B. "I will lose protein in my urine." C. "I should expect my provider to prescribe a kidney biopsy." D. "I should increase my sodium intake."
D
The nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in their clients plan of care to assist with elimination? A. Stroke the medial aspect of the thigh B. Use intermittent cauterization C. Provide digital anal stimulation D. Use the Valsalva maneuver
D
The patient is treated in the ED for status epilepticus and is admitted to the hospital. The physician has ordered seizure precautions. What equipment does the nurse place in the room prior to the patient's arrival? A. Cardiac monitor and pulse ox B. Penlight and a neurological flow sheet C. Padded tongue blades and padding for side rales D. Oxygen and suction equipment
D
What is a likely cause of viral meningitis? A. Lumbar puncture B. Intraventricular catheter C. Traumatic Injury D. Lack of immunization against mumps
D
Which assessment finding is most likely to occur in a client with diabetes insipidus? A. Hypertension B. Urine-specific gravity 1.005 C. Serum sodium 140 mg/dL D. Urine osmolality 180 mOsm/kg
D
Which electrocardiographic change indicates worsened hyperkalemia in a client with acute kidney failure? A. Flattened T wave B. Widened P wave C. Narrowed QRS complex D. Peaked T wave
D
Which intervention should the nurse implement for the client admitted to the intensive care unit with encephalitis? a. restrict the client's water intake b. position the client's bed next to a window c. allow the family to visit and talk to the client d. turn and reposition the client every two hours
D
In general, GBS is a chronic condition and the subsequent paralysis is permanent
False
The patient with myasthenia gravis is deficient in the neurotransmitter seotonin
False
The most successful treatment of GBS combines plasmapheresis and immunoglobulin
False (no added benefit of using them together in combination)
The Tensilon test can be used to distinguish between a cholinergic crisis and a myasthenic crisis
True
Although the onset of myasthenia gravis is usually insidious (slow), some instances of fairly rapid development have been caused by infection, emotional upset, pregnancy or anesthesia
True
Evidence suggests a relationship between myasthenia gravis and hyperplasia of the thymus gland
True
For a patient with GBS, the nurse assesses the patient's motor (muscle) function every 2-4 hours as part of the neurologic assessment
True
GBS is the result of a variety of related immune-mediated pathologic processes
True
Myasthenia gravis is characterized by remission and exacerbations
True
Risk factors for GBS include an upper respiratory tract infection or GI illness and positive antibodies to cytomegalovirus or Epstein-Barr virus (EBV)
True
