Med - Surg Practice Questions
Which explanation will the nurse give when a client asks about what causes varicose veins? "Abnormal configurations of the veins." "Incompetent valves of superficial veins." "Decreased pressure within the deep veins." "Atherosclerotic plaque formation in the veins."
"Incompetent valves of superficial veins." Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
Which amount is the normal value of a client's inspiratory reserve volume? 0.5 L 1.0 L 1.5 L 3.0 L
3.0 L The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.
Which would the nurse use to perform hand hygiene when caring for an immunocompromised client? Soap Betadine Chlorhexidine Alcohol-based hand sanitizer
Chlorhexidine Chlorhexidine will be used for hand hygiene when caring for immunocompromised clients because it decreases the risk of spreading infection. Cleansing hands with soap and alcohol-based hand sanitizers is not as effective at preventing the spread of infection. Betadine is not used for hand hygiene.
Which structure lies inside and parallel to the sclera? Lens Choroid Conjunctiva Ciliary processes
Choroid The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina. It lies parallel to the sclera. The lens is located behind the iris. The conjunctiva covers the inner surfaces of the eyelids and also extends over the sclera. The ciliary processes lie behind the peripheral part of the iris.
Which medication is used in the treatment of a client with intervertebral disc disease? Etidronate Zoledronic acid Cyclobenzaprine Salmon calcitonin
Cyclobenzaprine Intervertebral disc disease often causes myalgia. Muscle relaxants, such as cyclobenzaprine, are used in its treatment. Etidronate, zoledronic acid, and salmon calcitonin are effective in the treatment of osteoporosis.
Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food? Mucositis Dysgeusia Dysphagia Xerostomia
Dysgeusia Dysgeusia is the loss of the ability to taste, which can occur after treatment for cancer. Mucositis is the inflammation and irritation of the mucosa in the mouth or throat. Dysphagia is difficulty in swallowing or an inability to swallow. Xerostomia is dry mouth. All four of these complaints are common side effects of chemotherapy or radiation treatment.
Which is the etiological factor of nephrogenic diabetes insipidus (DI)? Meningitis Lithium therapy Graves disease Sulfonamide therapy
Lithium therapy Lithium therapy is the etiological factor of nephrogenic DI. Central nervous system infections such as meningitis are etiological factors of central DI. Goiter, an enlarged thyroid gland, is commonly seen in clients with Graves disease. Sulfonamide is a goitrogen that can cause goiter.
Which hormones are secreted by the posterior pituitary gland? Select all that apply. One, some, or all responses may be correct. Oxytocin Prolactin Corticotropin Antidiuretic hormone Melanocyte-stimulating hormone
Oxytocin Antidiuretic hormone Oxytocin and antidiuretic hormone (vasopressin) are secreted by the posterior pituitary gland. Prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland.
Which hormone has both inhibiting and releasing action? Prolactin Somatostatin Somatotropin Gonadotropin
Prolactin Prolactin secreted by the hypothalamus has both inhibiting and releasing action. Somatostatin inhibits the secretion of growth hormone. Somatotropin and gonadotropin are releasing hormones.
Which function of the dermis is accurate? Provides cells for wound healing Assists in retention of body heat Acts as mechanical shock absorber Inhibits proliferation of microorganisms
Provides cells for wound healing The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber. Epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms.
The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? P wave T wave PR interval QRS complex
QRS complex The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. Normally a P wave indicates that the sinoatrial node initiated the impulse that depolarized the atrium. The T wave represents ventricular repolarization. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval and represents depolarization of the sinoatrial node, both atria, and the atrioventricular node.
The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select? Levin Dobhoff Salem sump Gastrostomy
Salem sump A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.
Which virus can cause encephalitis in adults and children? Rubella virus Parvovirus Rotaviruses West Nile virus
West Nile virus The West Nile virus causes encephalitis. German measles is caused by the rubella virus. Gastroenteritis is caused by parvovirus. Rotaviruses also cause gastroenteritis.
Which condition can be identified in a client using Phalen's test? Atrophy Bone tumor Rotator cuff injury Carpal tunnel syndrome
Carpal tunnel syndrome Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.
Which type of cast or splint will the nurse expect to see on a child with a fractured femur? Cylinder Hip spica Prefabricated knee Robert Jones
Hip spica A hip spica cast is now mainly used for femur fractures in children. A cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle. A prefabricated knee splint is a commonly used cast for lower extremity injuries. A Robert Jones dressing is composed of bulky padding materials, splints, and elastic wrap or stockinette used for lower extremity injuries.
Which medication used in the treatment of clients with glaucoma is a prostaglandin agonist? Carteolol Bimatoprost Brinzolamide Apraclonidine
Bimatoprost Bimatoprost is the prostaglandin agonist used in the treatment of glaucoma. Carteolol is the beta-adrenergic blocker used for the treatment of glaucoma. Brinzolamide is the carbonic anhydrate inhibitor used for the treatment of glaucoma. Apraclonidine is the adrenergic agonist used in the treatment of glaucoma.
A deficiency in which hormone reduces the growth of axillae and pubic hair in female clients? Growth hormone Antidiuretic hormone Thyroid-stimulating hormone Adrenocorticotropic hormone
Adrenocorticotropic hormone An adrenocorticotropic hormone deficiency causes a reduced growth of axillae and pubic hair in women. A growth hormone deficiency causes decreased muscle strength and decreased bone density. An antidiuretic hormone deficiency causes excessive urine output and a low urine specific gravity. A thyroid-stimulating hormone deficiency results in hirsutism and menstrual abnormalities.
The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? Vesicular Bronchial Adventitious Bronchovesicular
Adventitious Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.
Which clinical manifestations indicate the chronic persistent stage of Lyme disease? Select all that apply. One, some, or all responses may be correct. Arthritis Dyspnea Dizziness Chronic fatigue Erythema migrans
Arthritis Chronic fatigue Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi. The symptoms of the chronic persistent stage are arthritis and chronic fatigue. Dyspnea and dizziness are the symptoms of the early disseminated stage. Erythema migrans is observed in the localized stage.
Which condition is associated with unevenly curved surfaces of the client's cornea? Myopia Hyperopia Emmetropia Astigmatism
Astigmatism Astigmatism is a refractive error caused by unevenly curved surfaces on or in the eye, especially of the cornea. These uneven surfaces distort vision. Myopia (nearsightedness) occurs when the eye overbends the light and images converge in front of the retina. Hyperopia (farsightedness) occurs when the eye does not refract light enough. As a result, images actually converge behind the retina. Emmetropia is the perfect refraction of the eye, in which light rays from a distant source are focused into a sharp image on the retina.
Which sign or symptom would the nurse expect to find on assessment of a client with a blood glucose level of 55 mg/dL? Select all that apply. One, some, or all responses may be correct. Increased thirst Abdominal pain Frequent urination Cold, clammy skin 3+ glucose in urinalysis
Cold, clammy skin A client with a blood glucose level of 55 mg/dL indicates hypoglycemia. Clinical manifestations would include cold, clammy skin; tachycardia; nervousness; and slurred speech. A client with hyperglycemia would present with increased thirst (polydipsia), abdominal pain, increased urination (polyuria), and polyphagia. The client with hyperglycemia would have glycosuria.
Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? Prevents bronchial spasm Decreases air trapping in lung Improves alveolar surface area Strengthens diaphragmatic contraction
Decreases air trapping in lung Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.
Which test is used in the diagnosis of systemic lupus erythematosus? Patch test Photo patch test Direct immunofluorescence test Indirect immunofluorescence test
Direct immunofluorescence test A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.
Which hormone aids in regulating intestinal calcium and phosphorous absorption? Insulin Thyroxine Glucocorticoids Parathyroid hormone
Glucocorticoids Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.
The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are consistent with which condition? Glaucoma Hypertension Hyperthyroidism Sinus infection
Hyperthyroidism Visual changes, such as blurring or double vision and tiring of the eyes, may be among the earliest problems for a client with hyperthyroidism. Exophthalmos, or protruding eyes, is also seen with hyperthyroidism. Glaucoma, hypertension, and sinus infection are not associated with exophthalmos.
Which symptom indicates a client with inhalation anthrax is in the fulminant stage? Low-grade fever Dry cough Hypoxia Mild chest pain
Hypoxia Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. This disease has two stages of illness, the prodromal stage and the fulminant stage. Hypoxia develops in the fulminant stage of the disease. Symptoms of low-grade fever, dry cough and mild chest pain will manifest during the prodromal stage of illness.
Which statement indicates the nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)? It is most common in women. It is manifested by intense bilateral pain. It is caused by an overactive hypothalamus. It is associated with headaches of long duration.
It is caused by an overactive hypothalamus. According to neuroimaging studies, the cause of cluster headaches is related to an overactive and enlarged hypothalamus. Cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours.
Which predisposing condition may be present in a client with pitting edema? Shock Kidney disease Hypothyroidism Severe dehydration
Kidney disease Kidney disease may be a predisposing condition associated with pitting edema. Shock may be associated with a decreased temperature. Hypothyroidism may be a predisposing condition of nonpitting edema, which occurs due to an endocrine imbalance. Severe dehydration may be associated with decreased elasticity of the dermis.
Which finding in a urinalysis indicates a urinary tract infection? Crystals Bilirubin Ketones Leukoesterase
Leukoesterase Leukoesterases are released by white blood cells in response to an infection or inflammation. The presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.
Which hormones are released by the hypothalamus? Select all that apply. One, some, or all responses may be correct. Follicle-stimulating hormone (FSH) Thyroid-stimulating hormone (TSH) Melanocyte-inhibiting hormone (MIH) Corticotropin-releasing hormone (CRH) Growth hormone-releasing hormone (GHRH)
Melanocyte-inhibiting hormone (MIH) Corticotropin-releasing hormone (CRH) Growth hormone-releasing hormone (GHRH) The hypothalamus is a small area of nerve and endocrine tissue located beneath the thalamus in the brain. MIH, CRH, and GHRH are released by the hypothalamus. FSH and TSH are released by the anterior pituitary gland.
Which client conditions does the nurse associate with bluish-colored mucous membranes? Select all that apply. One, some, or all responses may be correct. Edema Diabetes mellitus Hemochromatosis Methemoglobinemia Cardiopulmonary disease
Methemoglobinemia Cardiopulmonary disease A bluish color of the mucous membranes may indicate methemoglobinemia (the presence of methemoglobin in the blood, which is an oxidized form of hemoglobin) and cardiopulmonary disease in the client. The presence of a white color of the mucous membranes may indicate edema in the client. Diabetes mellitus is associated with a yellow-orange color of the palms and soles. The presence of a brown color of the distal lower extremities may indicate hemochromatosis (deposition of iron salts in the tissues).
Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? Electrical stimulation Topical growth factors Hyperbaric oxygen therapy Negative pressure wound therapy
Negative pressure wound therapy Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.
After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding? Dull Flat Tympanic Resonance
Resonance Resonance is a low-pitched hollow sound normally heard over the air-filled lungs during percussion in healthy individuals. Dullness is a medium-pitched "thud-like" sound that might be heard with problems like lung consolidation due to pneumonia. Flatness is a high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds are high-pitched and musical; tympany might be heard over a pneumothorax.
A nurse educator instructs a new nurse during orientation about the physiological processes of the endocrine system. Which statement made by the new nurse indicates effective learning? "The endocrine system comprises glands with narrow ducts." "The endocrine system comprises salivary and lacrimal glands." "The hormones of the endocrine system exert their action by 'lock and key' mechanism." "The hormones secreted by endocrine system exert their action on all tissues they contact."
"The hormones of the endocrine system exert their action by 'lock and key' mechanism." The endocrine glands secrete hormones that exert their action on the target tissues by the "lock and key" mechanism. The hormones recognize and adhere only to specific receptor sites on the target tissue, like a correct key alone can open its specific lock. The glands of the endocrine system are ductless and secrete hormones that are carried via the blood circulation. Salivary and lacrimal glands are not endocrine but secretory glands. The hormones are carried via blood to various tissues, but they exert their action only on specific target tissues.
The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching? "Before I start the procedure, I will don sterile gloves." "Before I start the procedure, I will obtain my body weight." "Before I start the procedure, I will measure the residual volume." "Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid."
"Before I start the procedure, I will measure the residual volume." Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200 mL, a feeding may be held. This safety measure prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly or monthly weights, depending on the client's condition and clinical goals. If the tube becomes clogged, the client may instill 30 mL of a carbonated beverage; this action is not used routinely.
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? "I have abnormal platelets." "I have abnormal hemoglobin." "I have abnormal hematocrit." "I have abnormal white blood cells."
"I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
When teaching a client self-care measures to prevent dry skin, which client statement indicates misunderstanding of the content? "I will decrease intake of caffeine and alcohol." "I will use deodorant soap in place of alkaline soap." "I will wear splints at night to prevent scratching in a deep sleep." " I will adjust my thermostat to remain around 74°F to 78°F (23.3°C-25.5°C)."
"I will use deodorant soap in place of alkaline soap." Avoiding caffeine and alcohol will prevent development of dry skin. Wearing splints will prevent damage to dry skin caused by scratching during deep sleep due to pruritus. Higher temperatures lead to increased perspiration and itching. Keeping the client's environment cooler will decrease the itching. Use of deodorant soap will make the skin dry, further, so the nurse needs to follow up to correct this misconception. Clients should avoid deodorant soap when experiencing dry skin.
How would the nurse respond to a client who expresses malignancy fears associated with the pending bone biopsy report? "Worrying is not going to help the situation." "Let's wait until we hear what the biopsy report says." "It is very upsetting to have to wait for a biopsy report." "Operations are not performed unless there are no other options."
"It is very upsetting to have to wait for a biopsy report." "It is very upsetting to have to wait for a biopsy report," addresses the fact that the client's feelings of anxiety are valid. Stating, "Worrying is not going to help the situation," or "Let's wait until we hear what the biopsy report says," does not address the client's concerns and may inhibit the expression of feelings. Telling the client that operations are not performed unless there are no other options is irrelevant and does not address the client's concerns.
When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive? "The other client's infection is not contagious." "This is the usual practice when antibiotic therapy is started." "Placing clients with the same infection in 1 room is safe." "As soon as a private room becomes available, we will move the client."
"Placing clients with the same infection in 1 room is safe." There is no need to separate 1 client with MRSA from another client with the same infection. MRSA infections are highly contagious. MRSA infections are resistant to most antibiotics, especially methicillin. Clients with the same infection can remain in the same room; contact precautions are necessary to protect visitors and staff members.
To ensure a quality specimen and an accurate test result, which instruction would the nurse give a client who is scheduled to undergo urine endocrine testing? "Start the urine collection when the bladder is full." "Store the urine specimen in a cooler with ice." "Store the urine specimen in a home refrigerator." "Save the urine specimen that begins the collection."
"Store the urine specimen in a cooler with ice." The urine specimen that is collected for endocrine testing should be stored in a cooler with ice to prevent bacterial growth in the specimen. The nurse should instruct the client to start the urine collection after emptying the bladder. The client should be instructed not to store the urine specimen in a home refrigerator with other food and drinks because it could lead to cross-contamination. The client should be instructed to refrain from saving the urine specimen that begins the collection because the timing for urine collection starts from after the initial voiding specimen.
7. Which information would the nurse include in explaining glaucoma to a client? An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina
An increase in the pressure within the eyeball An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.
Which joint helps in the gliding movement of the wrist? Pivot joint Hinge joint Biaxial joint Ball and socket joint
Biaxial joint The biaxial joint helps in the gliding movement of the wrist. Pivot joints permit rotation in the radioulnar area. Hinge joints allow for flexion and extension. Ball and socket joints permit movement in the shoulders and hips.
A client's respiratory tract infection, which started with a common cold, has progressed to whooping cough. The client reports "coughing fits" lasting for several minutes. Which organism is responsible for the client's condition? Bacillus anthracis Bordetella pertussis Streptococcus pneumoniae Mycobacterium tuberculosis
Bordetella pertussis Bordetella pertussis causes whooping cough . Pertussis is a respiratory tract infection beginning with the common cold and progresses to whooping cough. The client also develops coughing episodes lasting for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.
Which term refers to the Cowper gland? Skene gland Prostate gland Bartholin gland Bulbourethral gland
Bulbourethral gland Cowper glands are accessory glands of the male reproductive system; they are also referred to as the bulbourethral glands. Skene glands are a part of the female reproductive system. The prostate gland is also a gland of the male reproductive system. Bartholin glands are part of the female reproductive system.
When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate? Cordectomy Tracheotomy Total laryngectomy Oropharyngeal resections
Cordectomy A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and 1 or 2 tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.
A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change? Decrease portion size and fat intake. Increase protein and vegetable intake. Decrease carbohydrate and fat intake. Increase fruits and limit fluid intake.
Decrease portion size and fat intake The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are 4 calories each. Increasing protein intake can increase fat intake because animal protein also contains fat. Although decreasing carbohydrate and fat intake will promote weight loss, the diet may result in an imbalance of nutrients, which may jeopardize the client's health. Fruits are important in any diet, and if a balance of nutrients is to be maintained, fruit intake may need to be increased or decreased depending on the client's eating habits. Water intake should not be limited in a weight loss diet.
Which changes with a client's hair would be responsible developing white hair at the age of 23? Decreased oils Decreased density Decreased estrogen levels Decreased melanocytes
Decreased melanocytes White hair appears in a client when a decrease in melanin and melanocytes occurs. Dry, coarse hair occurs when there is a decrease in oils. Thinning and loss of hair are due to decreased hair density. Facial hirsutism is due to decreased levels of estrogens.
Which virus is responsible for causing infectious mononucleosis in clients? Parvovirus Coronavirus Rotavirus Epstein-Barr virus
Epstein-Barr virus Epstein-Barr virus is responsible for mononucleosis and possibly Burkitt lymphoma. Parvovirus and rotavirus cause gastroenteritis. Coronavirus causes upper respiratory tract infections.
A client reports their lips feel thicker, and they have joint pain and coarse facial features. The nurse would suspect an excessive secretion of which hormone? Growth hormone Prolactin hormone Thyroid-stimulating hormone Adrenocorticotropic hormone
Growth hormone Thickened lips, joint pain, and coarse facial features are the symptoms of acromegaly, which is caused by pituitary gland hyperfunction leading to excessive secretion of growth hormone. Prolactin hormone hypersecretion can cause hypogonadism, which is loss of sexual characteristics. Thyroid-stimulating hormone hypersecretion can result in increases in both plasma thyroid-stimulating hormone and thyroid hormone levels. Adrenocorticotropic hormone hypersecretion can cause Cushing disease characterized by increased plasma cortisol levels.
Which type of hepatitis virus spreads through contaminated food and water? Hepatitis A virus Hepatitis B virus Hepatitis C virus Hepatitis D virus
Hepatitis A virus Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.
The nurse is educating a couple concerning the process of fertilization. Which hormone would the nurse explain as stimulating the release of estrogen and progesterone after fertilization? Inhibin Testosterone Follicle-stimulating hormone (FSH) Human chorionic gonadotropin (hCG)
Human chorionic gonadotropin (hCG) After fertilization, human chorionic gonadotropin (hCG) stimulates the corpus luteum to produce estrogen and progesterone. Inhibin is a hormone produced by the ovarian follicles; it inhibits the secretion of FSH and gonadotropin-releasing hormone. Testosterone does not affect the release of estrogen and progesterone. Follicle-stimulating hormone (FSH) stimulates the growth and maturity of the ovarian follicle necessary for ovulation.
Which physical symptoms would a client diagnosed with Cushing syndrome exhibit? Fever and tachycardia Lethargy and constipation Hypertension and moon face Hyperactivity and exophthalmos
Hypertension and moon face Increased glucocorticoids cause sodium and water retention, hypertension, and fat deposition, resulting in a moon face. Fever, tachycardia, hyperactivity, and exophthalmos are associated with hyperthyroidism. Lethargy and constipation are associated with hypothyroidism.
Which type of immunoglobulin is present in tears, saliva, and breast milk? IgE IgA IgG IgM
IgA IgA immunoglobulin is present in tears, saliva, and breast milk. IgE and IgG immunoglobulins are present in plasma and interstitial fluids. IgM immunoglobulin is present in plasma.
Which immunoglobulin crosses the placenta? IgE IgA IgG IgM
IgG IgG is the only immunoglobulin that crosses the placenta. IgE is found in the plasma and interstitial fluids. IgA lines the mucous membranes and protects body surfaces. IgM is found in plasma; this immunoglobulin activates due to the invasion of ABO blood antigens.
A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary health care provider? Shingles Impetigo Folliculitis Verruca vulgaris
Impetigo Impetigo is a primary bacterial infection most common on the face. This is clinically manifested as vesiculopustular lesions that develop as thick, honey-colored crust surrounded by erythema. Shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, and lumbosacral areas. Folliculitis is a bacterial infection seen most commonly on the scalp, beard, and extremities in men. Verruca vulgaris is a viral infection that is clinically manifested as a circumscribed, hypertrophic, flesh-colored papule limited to the epidermis.
Which infection would the nurse identify as requiring a client to be placed on droplet precautions? Human immunodeficiency virus (HIV) Influenza Tuberculosis (TB) Methicillin-resistant Staphylococcus aureus (MRSA)
Influenza Clients with influenza will be placed on droplet precautions because the infection can be spread by talking or sneezing. HIV-positive clients will be instructed to use barrier protection with any kind of sexual contact to prevent spread of the virus. Clients with TB will be placed on airborne transmission precautions. Clients with MRSA would require contact precautions.
A client who previously resided in a foreign country has a chronic vitamin A deficiency. Which information about vitamin A would the nurse consider when assessing the client? Vitamin A is an integral part of the retina's pigment called melanin. It is a component of the rods and cones, which control color visualization. Vitamin A is the material in the cornea that prevents the formation of cataracts. It is a necessary element of rhodopsin, which controls responses to light and dark environments.
It is a necessary element of rhodopsin, which controls responses to light and dark environments. Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.
Which nursing action would be implemented after a client has a lumbar puncture? Maintaining the client in the supine position for several hours Encouraging the client to ambulate every hour for at least 6 hours Keeping the client in the Trendelenburg position for at least 2 hours Placing the client in the high-Fowler position immediately after the procedure
Maintaining the client in the supine position for several hours Staying flat may help prevent spinal fluid leakage and postprocedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat.
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate? No protein Moderate protein High protein Strict protein restriction
Moderate protein Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no-protein restrictions are not required because the client needs protein for healing. The hepatic encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.
Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Severe muscle cramps Numbness around the mouth
Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild to moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice? Necrosis of the parenchyma caused by the neoplasm Excessive serum bilirubin caused by red blood cell destruction Obstruction of the common bile duct by the pancreatic neoplasm Impaired liver function, resulting in incomplete bilirubin metabolism
Obstruction of the common bile duct by the pancreatic neoplasm The common bile duct passes through the head of the pancreas; the neoplasm often constricts or obstructs the duct, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.
Which group of clients would the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas? Children Older adults Young adults Middle-aged persons
Older adults Middle-aged persons The incidence of non-Hodgkin lymphoma increases with age; the disease is more common in men and older adults. Younger individuals have a lower incidence of non-Hodgkin lymphomas.
Which part of the female reproductive system produces testosterone? Uterus Ovary Fallopian tube Ovarian follicle
Ovary Testosterone is an androgen, and in females, androgens are produced by the ovaries and adrenal glands. The uterus holds the fetus during pregnancy. Fallopian tubes facilitate fertilization of oocyte and sperm. An ovarian follicle is a collection of oocytes in the ovary.
The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m2? Obese Normal Overweight Underweight
Overweight A BMI between 25 and 29.9 kg/m2 places the client in the overweight category. A BMI of 30 kg/m2 is considered obese. A normal BMI is between 18.5 kg/m2 and 24.9 kg/m2. A BMI below 18.5 kg/m2 is considered underweight.
Which hormone promotes bone resorption in a client and potentially leads to decreased bone densities? Estrogen Calcitonin Growth hormone Parathyroid hormone (PTH)
Parathyroid hormone (PTH) When serum calcium levels lower, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which promotes bone resorption. Estrogens stimulate osteoblastic (bone-building) activity and inhibit PTH. Calcitonin inhibits bone resorption and increases the renal excretion of calcium and phosphorus as needed to maintain balance in the body. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length.
Which synovial joint movement is involved in turning a client's palm downward? Eversion Inversion Pronation Supination
Pronation Pronation is the movement involved in turning the palm downward. Eversion involves turning the sole outward away from the midline of the body. Inversion involves turning the sole inward towards the midline of the body. Supination involves turning the palm upward.
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? Proteus Bacteroides Pseudomonas Staphylococcus
Pseudomonas The purulent exudates of greenish-blue pus with a fruity odor signifies colonization with Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.
Which process is a function of the kidney hormones? Prostaglandin increases blood flow and vascular permeability. Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. Renin raises blood pressure because of angiotensin and aldosterone secretion. Erythropoietin promotes calcium absorption in the gastrointestinal tract tract.
Renin raises blood pressure because of angiotensin and aldosterone secretion. Renin is a kidney hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. Prostaglandin is a kidney hormone that regulates intrarenal blood flow via vasodilation or vasoconstriction. Bradykinin is a kidney hormone that increases blood flow and vascular permeability. Erythropoietin is a kidney hormone that stimulates the bone marrow to make red blood cells.
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is the priority? Urinary output Sensation to touch Neurological status Respiratory exchange
Respiratory exchange The ascending paralysis of Guillain-Barré syndrome can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurological status are important, none of them are the priority.
Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis? Repositioning Humidified air Saline irrigation Frequent suctioning
Saline irrigation Saline irrigation of the nasal cavity facilitates drainage and decreases inflammation, allowing the client to breathe more comfortably. Repositioning a client does not specifically relieve the symptoms of sinusitis. Humidity prevents drying of the nasal passages. The nasal passages are not suctioned for a client with sinusitis.
Which gland is an exocrine gland? Thyroid gland Salivary gland Pituitary gland Parathyroid gland
Salivary gland Exocrine glands are glands with ducts that produce enzymes but not hormones. These glands secrete enzymes into ducts. The salivary gland secreting saliva is an example of an exocrine gland. Endocrine glands are ductless glands that produce hormones that are secreted into the blood. Thyroid, pituitary, and parathyroid glands are examples of endocrine glands.
Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically? Enzymatic agents Scissors and forceps Autolytic semiocclusive dressing Continuous passive-motion device
Scissors and forceps Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.
Which physiological changes of the musculoskeletal system would the nurse associate with aging? Select all that apply. One, some, or all responses may be correct. Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence
Slowed movement Cartilage degeneration Increased bone prominence The physiological changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.
Which action will the nurse take to determine a client's pulse pressure? Multiply the heart rate by the stroke volume. Subtract the diastolic from the systolic reading. Average the systolic and diastolic pressure readings. Calculate the difference between apical and radial pulse rates.
Subtract the diastolic from the systolic reading. Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest
Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurological dysfunction; it is not an indication of a fat embolism.
Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts? Limbic lobe Frontal lobe Occipital lobe Temporal lobe
Temporal lobe Wernicke's area (language area), which allows processing of words into coherent thought and understanding of written or spoken words, is located in the temporal lobe. The limbic lobe controls the emotional and visceral patterns in the brain. The frontal lobe consists of Broca's area, which is the speech area responsible for formation of words into speech. The occipital lobe contains the primary visual center.
A client had an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10 mm within 48 hours after planting. Which conclusion would the nurse make about the client's response to this diagnostic? The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus.
The client has been exposed to the tubercle bacillus. Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive tuberculin purified protein derivative indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care? The disease process and breathing exercises How to control or prevent respiratory infections Using aerosol therapy, especially nebulizers Priorities when performing everyday activities
The disease process and breathing exercises Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.
Which fungal infection does the client refer to as jock itch? Tinea pedis Tinea cruris Tinea corporis Tinea unguium
Tinea cruris Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with a well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested as scaliness under the distal nail plate.
A client's sputum smears for acid-fast bacilli (AFB) are positive and requires transmission-based airborne precautions. Which instruction would the nurse teach when orienting the client's visitors? All visitors must wear a gown and gloves. Wear a particulate respirator mask when in the room. Avoid touching objects in the client's room. Limit contact with the client's nonexposed family members.
Wear a particulate respirator mask when in the room. Tubercle bacilli are transmitted through air currents; therefore personal protective equipment, such as a particulate respirator that filters out organisms as small as 1 µm, is necessary. Gowns and gloves are not necessary. Tuberculosis is spread by airborne microorganisms; gloves are necessary only when touching articles contaminated with respiratory secretions. It is only necessary to avoid contact with objects in the client's room that are contaminated with respiratory secretions. Limiting contact with the client's nonexposed family members is unnecessary.
After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? Crackles Wheezes Rhonchus Pleural friction rub
Wheezes Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.
