Med surge 2 final

A nurse in a provider's office is obtaining a nursing history from a client who has migraine headaches. Which symptoms would validate this diagnosis? Select all 1 Client experiences photophobia 2 Clients experiences nausea and vomiting 3 Client states that increasing physical activity alleviates the pain 4 Client states that symptoms improve if she sits in a bright lit room 5 Client states that foods containing tyramine trigger the migraine

1 Client experiences photophobia 2 Clients experiences nausea and vomiting 5 Client states that foods containing tyramine trigger the migraine

The nurse is providing an in-service for a new group of nurses. The nurse is reviewing clinical findings that could indicate an increased ICP from a closed head injury. Which would she include in the discussion? (select all that apply) 1 Disorientation to time and place 2 Restlessness and irritability 3 Unilateral facial paralysis 4 Unequal pupils 5 Severe headache

1 Disorientation to time and place 2 Restlessness and irritability 4 Unequal pupils 5 Severe headache

The nurse is reviewing the health record of a client who has a middle ear disorder. Which of the following are expected findings? (select all that apply) 1 Enlarged adenoids 2 Report of recurrent colds 3 Bulging tympanic membrane 4 Light reflexes visible on otoscopic exam at 5 and 7 o'clock 5 Reports use of ototoxic medications

1 Enlarged adenoids 2 Report of recurrent colds 3 Bulging tympanic membrane

The nurse is contributing to the plan of care for a client admitted with an open head injury. Which of the following are interventions that should be included to prevent increased intracranial pressure? (select all that apply) 1 Keep head of bed elevated 30 degrees 2 Administer stool softeners 3 Encourage deep breathing and coughing 4 Avoid extreme flexion, extension or rotation of the head 5 Allow unlimited visitors 6 Administer oxygen to keep the oxygen saturation above 92%

1 Keep head of bed elevated 30 degrees 2 Administer stool softeners 4 Avoid extreme flexion, extension or rotation of the head 6 Administer oxygen to keep the oxygen saturation above 92%

The nurse is providing care for a client who has experienced a right-hemispheric stroke. Which of the following is an expected finding? Select all Alexia 1 Loss of depth perception 2 Right extremity hemiplegia or hemiparesis 3 Visual changes such as hemianopsia 4 Poor impulse control

1 Loss of depth perception 3 Visual changes such as hemianopsia 4 Poor impulse control

A client has just been admitted to the ER with an exacerbation of MS. Which of thr following common manifestations of multiple sclerosis(MS) should the nurse be expecting? (select all tat apply) 1 Muscle spasticity 2 Skin lesions 3 Dysphagia 4 Visual changes 5 Fatigue

1 Muscle spasticity 3 Dysphagia 4 Visual changes 5 Fatigue

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (select all that apply) 1 Reduce exposure to bright light 2 Avoid caffeine and alcohol 3 Avoid fruits high in potassium 4 Plan evenly spaced daily fluid intake 5 Take diuretics as prescribed

1 Reduce exposure to bright light 2 Avoid caffeine and alcohol 4 Plan evenly spaced daily fluid intake 5 Take diuretics as prescribed

The nurse is contributing to the plan od care for a client who has dysphagia. Which of the following should the nurse include in the plan of care? (select all that apply) 1. Have suction equipment available for use 2.Thicken liquids using a commercial thickener 3. Place food on the affected side of the client's mouth 4. Instruct the client to swallow with her neck flexed 5.If chocking occurs, let the client rest several minutes before continuing feeding

1. Have suction equipment available for use 2.Thicken liquids using a commercial thickener 5.If chocking occurs, let the client rest several minutes before continuing feeding

The nurse is caring for a client who was admitted to the hospital with respiratory difficulty after being diagnosed with ALS about 1 year ago. Which of the following client findings should the nurse anticipate? (select all that apply) 1. Muscle atrophy 2. Fluctuation in blood pressure 3. Dysphagia 4. Ineffective cough 5. Loss of cognitive function

1. Muscle atrophy 3. Dysphagia 4. Ineffective cough

The nurse is working in a long-term care facility. She is collecting data an older adult who is being observed for a transient ischemic attack (TIA). Which of the following are manifestation of a TIA?(select all that apply) 1. Unilateral numbness of the arm 2. Stiff neck 3. Dizziness 4. Slurred speech 5. Otorrhea

1. Unilateral numbness of the arm 3. Dizziness 4. Slurred speech

The nurse is planning care for several clients and is considering the client's risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke? A client who has uncontrolled hypertension A client who has chronic atrial fibrillation A client who has thrombocytopenia A client who has an arteriovenous malformation

A client who has chronic atrial fibrillation

The nurse is reinforcing information with a client who has a new diagnosis of rheumaaatid arthiritis (RA) which of the following statements by the nurse is appropriate?

A. YOU MAY EXPERIENCE MORNING STIFFNESS WHEN YOU GET OUT OF BED

The nurse, in conjunction with the patients, establishes a plan to treat the pain associated with rheumatid arthritis. The most effective strategy is to

APPLY WARM, MOIST COMPRESSES BEFORE DOING, ACTIVITY

A nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives at test dose of edrophonium (Tension). The nurse recalls that the client would hake which of the following reactions if the client does actually have this disease? An increase in muscle strength that lasts about 5 minutes A decrease in muscle strength within 5 minutes Joint pain for the next 15 minutes Feeling of faintness or dizziness for 5 to 10 minutes

An increase in muscle strength that lasts about 5 minutes

The nurse is providing discharge instructions for a client following outpatient cataracts surgery with insertion of an intraocular lens. Which of the following should the nurse include? Sunglasses will not be needed postoperatively There are no restrictions on tilting the head to wash hair It is normal to see flashes of light and/ or floating shapes Avoid sneezing, coughing or straining

Avoid sneezing, coughing or straining

The nurse is caring for a client who has been diagnosed with left homonymous hemianopsia. Which of the following actions by the nurse is appropriate? A. Tell the client to scan to the right to see objects on the right side of the body B. Place the client's bedside table on the right side of the bed C. Orient the client to food on a plate using the clock method D. Place the client's wheelchair on his left side

B. Place the client's bedside table on the right side of the bed

A client reports bilateral pain and swelling in her finger joints with stiffness in morning. The finger joint are erythematous and warm to the touch. The client tells the nurse that she has a long family history of arthritis. To help diagnose the clients condition the nurse anticipates an order for which laboratory study

B. RHEUMATOID FACTOR

The nurse is performing an otoscope examination of a client. Which of the following is an unexpected finding? Pearly gray tympanic membrane Malleus visible behind the tympanic membrane Visible light reflex at 5 o'clock in the right ear Black cerumen partially occluding the tympanic membrane

Black cerumen partially occluding the tympanic membrane

The nurse caring for a patient with HIV infection who is taking Retrovir, a nucleoside reverse transcriptase inhibitor. The nurse understands that understands that an antiretrovial medications can increase alamine aminotransferase (ALT), aspararate aminotransferense (AST), and bilirubin should be obersant for which of the following?

C. Jaundice

The nurse explains to a 51-year-old professional tennis instructor who is diagnosed with osteoarthritis that the disease is best understood as the: A. Presence of antibiotic in the synovial fluid B. Desolation of the patella over the tibia C.Progressive deterioration of the articular cartilage D.Body's autoimmune response

C.Progressive deterioration of the articular cartilage

41. A nurse in a clinic is collecting data from a client who has AIDS. which checking the clients mouth the nurse notes a white covering on the tongue and buccal membranes. The nurse recognizes this as a manifestation of

CANIDITASIS

A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE) who is experiencing an exacerbation of the illness. The nurse would expect which of the following medications to be prescribed by the PCP to manage the condition ?

CORTICOSTERIODS (PREDNISONE)

The nurse working in a provider's office is obtaining a nursing history from a client who has cluster headaches. Which of the following are expected findings? Client experiences mydriasis Client develops an aura Client has profuse facial sweating Client relates headaches are more frequent in the summer and winter

Client has profuse facial sweating

After a knee replacement, the 87-year-old patient rejects the use of the continuous passive motion machine (CPM). The nurse points out that of the CPM's benefits is a(a): A.Decrease in pain B. Increase in circulation in the new joint C. Increase in leg strength and muscle tone D. Help prevent scar tissue formation

D. Help prevent scar tissue formation

A client is admitted to the ER with complications of RA and is diagnosed with Sjogrens syndrome The nurse understands that this diagnosis presents with which of the following triad of symptoms?

DRY EYES, DRY MOUTH, AND DRY VAGINA

the LPN working in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse knows that which of the following factors can cause myasthenic crisis? Developing a respiratory infection Taking too much prescribe medication Not getting enough sleep Not exercising enough

Developing a respiratory infection

A nurse is caring for a client with severe head trauma. There has been a sudden rise in the ICP. The nurse suspects bran herniation. Which of the following signs and symptoms would BEST indicate this? Vertigo, hesitation, and dysphagia Disorientation, headache and nausea/vomiting Hemiparesis, photophobia, and vomiting Dilated pupils, Cheyne-strokes respirations, and deteriorating level of consciousness

Dilated pupils, Cheyne-strokes respirations, and deteriorating level of consciousness

The nurse is reinforcing teaching for female client diagnosis with SLE about factors that might trigger an exacerbation. The nurse determines that the client needs further teaching when she identifies which of the following as a factor that may cause an excerbation of SLE.

EXERCISE

The nurse is caring for a client in an extended care facility who has macular degeneration. Which of the following ADLs will the client required the greatest amount of assistance? Dressing Eating Toilet-ing Combing her hair

Eating

The nurse us caring for a patient with a traumatic brain injury. Which assessment finding alets the nurse to possible diabetes insipidus? Headache Confusion Frequent urination Elevate blood glucose

Frequent urination

The nurse is assisting in a teaching plan for the family of a patient with HIV. Which explanation about the transmission of HIV should the nurse include in this plan?

HIV SPREADS BY CONTACT WITH INFECTED BLOOD

The nurse is caring for a client with a left cerebral hemisphere infarct and right hemiplegia. The PCP ordered an evaluation by the speech pathologist. The speech pathologist reports that the client has expressive aphasia. Which nursing intervention is best communicating with the client at this time? Speak using a low tone of voice Have the client point to key phrases printed on a clipboard Complete the sentence of the client become frustrated Encourage the client practice verbalizing key words

Have the client point to key phrases printed on a clipboard

The nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? The bright light in this room is really bothering me My eye really itches, but I am trying not to rub it It's really hard to see with a patch on one eye I need something for the horrible pain in my eye

I need something for the horrible pain in my eye

A nurse is caring for a client who has MG and has reinforced instructions about that should be taken to decrease the risk of complications secondary to MG. which of the following client statements indicates a need for further teaching? I should take my Mestinon 1 hour before or 2 hours after a meal I have suction equipment at home in case I get really choked I will make sure I schedule at least a couple of rest period during the day I will put thickener in fluids that I drink when I am feeling tired

I should take my Mestinon 1 hour before or 2 hours after a meal

The nurse in the clinic is reinforcing teaching with a client who has a history of migraine headache about a new prescription for zolmitriptan (zoming). Which of the following statements by the client indicates understanding of the teaching? This medication will relieve my symptoms by causing my blood vessels to dilate This medication should prevent the headache from occurring I should take this medication as soon as I notice symptoms developing I should take this medication to lower my sensitivity to food triggers

I should take this medication as soon as I notice symptoms developing

The nurse has reinforced medications teaching with a patient who has rheumatoid arthritis. Which of the these medications, if stated by the patient, indicates to the nurse correct understanding of symptom control with a medication?

IBUPROPHEN

The nurse is caring for client who has seasonal allergy symptoms and had radioallergsorbent (RAST) testing completed during a prvious clinic visit. The recognizes that a positive results is indicated by an elevation of which of the following?

IGE

The nurse is caring for a Client with glaucoma. The client has been prescribed Pilocarpine eye drops to both eyes four time perday. The nurse knows that this medication has which expected action? Increase the outflow of aqueous humor Improves vision in dimly lit environments Increases the production of aqueous humor Increases the ability of both pupils to dilate

Increase the outflow of aqueous humor

The nurse is providing pre-procedure instructions for a client who is to undergo to electronystagmography (ENG) exam. Which of the following would be included in the nursing actions and client education? Instruct the client that the electrodes will placed behind his ears Instruct the client that he test may be performed even if he has a pacemaker Instruct the client that he does not need to restrict the use of antihistamines prior to the procedure Instruct the client that he should remind on bedrest until the vertigo subside

Instruct the client that he should remind on bedrest until the vertigo subside

A 72-year-old client has come to the ER with right-side weakness, experiencing aphasia, and slow behavior. The PCP has cone a CT scan and has confirmed an embolic stroke. The PCP asks the nurse to prepare for administrating tPA. The client asks what is medication is for. What is the BEST and most accurate response by the nurse? It enhances cerebral origination It dissolves the clot in your brain It promotes clotting in your brain It will prevent other clots from forming

It dissolves the clot in your brain

The nurse is assisting with teaching a patient who is beginning therapy with neostigmine (prostigmin) for newly diagnosed myasthenia gravis (MG). the patient asks, "how does that work?" what is the best response by the nurse? It provides potassium to you muscles so that they will contract better It reduces the inflammation in your nerves so that they transmit signals better It inhibits the breakdown of acetylcholine and increases muscle strength It is a muscle relaxant that prevents the cramping in your muscles

It inhibits the breakdown of acetylcholine and increases muscle strength

The nurse is helping to prepare a client with SLE for discharge. Which of the following instructions should the nurse include in the client's discharge teaching plan?

MONITOR YOUR BODY TEMPERATURE AND REPORT ANY CLEVATIONS PROMPTLY

A patient Is admitted to a medical unit with a cerebrovascular accident (stroke). The patient is flaccid on the left side and is unable to speak but seems to understand everything the nurse say. Which of the following terms would the nurse use to document the parent's communication impairment? Sensory aphasia Motor aphasia Motor dysphagia Receptive dysphagia

Motor aphasia

The nurse is assisting with a tonometry test on a patient at the ophthalmologist's office. The results indicate the patient's reading to be 15 mm Hg. The nurse interprets this result as____IOP Decreased Normal Slightly increased Severely increased

Normal

The nurse is caring for an older client who has diabetes mellitus. The client reports loss of peripheral vision and mild eye pain. For which of the following is the client at risk? Cataracts Open-angle glaucoma Macular degeneration Ange-closure glaucoma

Open-angle glaucoma

The nurse is caring for client who has SLE and is experiencing an episode of Raynauds phenomenon . Which of the following clinical findings should the nurse anticapate?

PALLOR OF TOES AND FINGERS WITH COLD EXPOSURE

The nurse is admitting a client diagnosed with possible SLE. Which assessment data observed by the nurse support the diagnosis of SLE?

PERICARDIAL FRICTION FRICTION RUB AND DIMINISHED BREATH SOUNDS

The 26 year old female client is complaining of a low grade fever, arthralgia, fatigue, and a facial rash Which laboratory tests would be most specific if SLE is suspected ?

POSITIVE ANTI-SMITH TEST

The nurse is caring for a client with HIV. The nurse knows that antiretroviral drugs are used in the treatment of human immunodeficicy virus (HIV) infection to

PREVENT REPLICATION OF NEW VIRUS

The client with acquired immundeficiency syndrome is diagnosed with cutaneous Kaposi's sarcacoma based n this disagnosis, the nurse understands that nurse understands that this has been confirmed by which?

PUNCH BIPOSY OF THE CUTANEOUS LESIONS

the LPN is reviewing discharge instructions with a family member on the interventions for safe swallowing for a client who has residual effects from a stroke. Which of the following concepts are most important for the family members to understand? Offer mouth care before meals Place food in the affected side of the mouth Encourage the client to take small bite and chew food thoroughly Place the client in the upright position for facilitate swallowing

Place the client in the upright position for facilitate swallowing

The nurse is caring for a client experiencing an acute exacerbation of multiple sclerosis (MS). The nurse recognizes that symptoms of MS are caused by with of the following pathophysiological changes? Myelin buildup in the central nervous system Gamma aminobutyric acid (GABA) deficiency Reduced acetylcholine receptors with impaired nerve impulse transmission Plaque damages the myelin sheath and interferes with impulse transmission

Plaque damages the myelin sheath and interferes with impulse transmission

The nurse is caring for a client who has Meniere's disease. When asked by the client if he is allowed to ambulate independently, which of the following is an appropriate response by the nurse? Yes, you are free to move around as you wish No, you are strict bedrest and must not be up Please ring for assisting when you wish to get out of bed We will have to get an order from your provider

Please ring for assisting when you wish to get out of bed

The nurse is caring for a client admitted with an acute exacerbation pf her multiple sclerosis. Which drug thearchy does the nurse anticipate administering to help resolve an exacerbation? Pyridostigmine (mestinon) Prednisone (rayos) Tyrotropin Diphenhydramine (Benadryl)

Prednisone (rayos)

When collecting data from a client who has Kaposi's sarcoma, the nurse should expect to observe which of the following?

REDDISH PURPLE SKIN LESIONS

The nurse is assisting with the admission of a client with a confusion following a motor vehicle accident. The nurse's observation of this client should include monitoring for early signs od increasing intracranial pressure including: bradycardia Ipsilateral pupil dilation (on same side as injury) Nuchal rigidity Restlessness and irritability

Restlessness and irritability

The HCO is treating a 46 year old male recently diagnosed with ADL. The patient is being started on a glutamate antagonist. The client asks you why he needs to take this medication? Which of the best response by the nurse? IV Immunoglobulin will suppress the attack on your immune system Azathioprine (Imuran) is used to prevent relapses Mestinon (pyridostigmine) will decrease your muscle strength Rilutek (riluzole) will slow deterioration of the motor neurons

Rilutek (riluzole) will slow deterioration of the motor neurons

The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment fining should the nurse expect to observe? The leg-flexes when the patellar tendons is stuck The leg extends when the patellar tendon is stuck The big toe extends and the other toes fan out when the sole of the foot is stroked Toes curl downward when the sole of the foot is stroked

The big toe extends and the other toes fan out when the sole of the foot is stroked

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, what of the following is most important for the nurse to include to to include? The need to decrease table salt in the diet The need for lifelong medication therapy The need to restrict fluid on order to reduce intraocular pressure The need to avoid straining or overworking the eyes

The need for lifelong medication therapy

The nurse is caring for a client with an expanding brain tumor and reviewing the client's medications. The clients has been prescribe Dexamethasone (a corticosteroid). Which of the following is an appropriate statement by the nurse? The client can experience hypoglycemia This medication is prescribed to reduce cerebral edema The client can expect to lose weight This medication will cause the tumor to shrink

This medication is prescribed to reduce cerebral edema

The nurse is caring for a client with a subdural hematoma. The client becomes restless and confused with dilatation of the ipsilateral pupil (pupil om the same side as the injury). The PCP orders mannitol. What is the reason for ordering this medication? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease intracranial pressure (ICP) To draw water into the vascular system to increase blood pressure

To promote osmotic diuresis to decrease intracranial pressure (ICP)

The nurse us discussing the care for a client who has suspected Meniere's Disease. What would the nurse say is an expected finding? Presence of a purulent lesion in the external ear canal Recent history of plane travel Bulging, red bilateral tympanic membranes Unilateral sensorineural hearing loss

Unilateral sensorineural hearing loss

The nurse is reinforcing teaching for a client who has glaucoma. Which of the following statement is appropriate? Without treatment glaucoma can cause blindness Double vision is a common symptom of glaucoma Glaucoma results from inadequate production of fluid within the eye You will need to treat glaucoma by instilling eye drops once a week

Without treatment glaucoma can cause blindness

the nurse is reviewing information on diverticulitis with a newly hired LPN. what should be included in the information? a. a high fiber diet can predispose a client to the development of diverticula b. the client will usually have right lower quadrant pain c. the WBC count will be decreased d. stool may be positive for occult blood

a. a high fiber diet can predispose a client to the development of diverticula

the nurse is giving a lecture on risk factors for colon cancer to a group of LPN students. which of the following is a risk factor for colon cancer and should be included in the lecture? a. adenomatous colon polyps b. low fat, high fiber diet c. diet with increased fresh fruits and vegetables d. age less than 50

a. adenomatous colon polyps

the nurse is providing care for a client with cirrhosis who is schreduled to undergo a liver biopsy. which potential complication does the nurse monitor for inmediately after the procedure? a. bleeding b. infection c. blood clots d. collapsed lung

a. bleeding

the nurse is caring for a pt with an exacerbation of crohn's disease. which nursing action is most important to recommend in the pt's plan of care? a. encourage oral fluids b. encourage frequent ambulation c. administer anti-gas agents as ordered d. apply protective ointment to perianal skin

a. encourage oral fluids

the nurse is caring for a client who has hepatitis A. the client asks the nurse how he might have contracted the virus. before responding, which of the following questions should the nurse ask the client? a. have you eaten any shellfish lterm-80ately b. did you have a blood transfusion recently c. have you traveled to a third world country in the past 2 months d. do you take any recreational drugs

a. have you eaten any shellfish lately

the nurse is assisting in creating a plan of care for a client who has advanced cirrhosis. which of the following manifestations should the nurse expect to find? a. petechiae b. vitaminc C deficiency c. osteoarthritis d. peripheral ulcers

a. petechiae

A nurse with myasthenia gravis (MG) is receiving pyridostigmine (mestinon). The nurse monitor for signs and symptoms of cholinergic crisis caused by as overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? Vitamin K atropine sulfate protamine sulfate acetylcysteine (mucomyst)

atropine sulfate

the nurse is reinforcing teaching provided to a patient chronic liver failure. what should the patient be instructed to help prevent injury? a. drink plenty of clear fluids b. brush your teeth with a soft-bristled brush c. be sure to get 20 minutes of exercise daily d. take an aspirin a day to prevent heart complication

b. brush your teeth with a soft-bristled brush

the nurse is collecting date for a patient with acute pancreatitis. which laboratory test result should the nurse expect? a. decreased serum lipase b. elevated serum amylase c. elevated srum albumin d. decreased serum ammonia

b. elevated serum amylase

the nurse is providing care for a client who has a laparoscopic cholecystectomy. whih of the following is an appropriate nursing action ? a. place the client in a supine position b. encourage ambulation on the day of surgery c. offer the client ice cream post-operatively d. change adhesive bandages on the day of surgery

b. encourage ambulation on the day of surgery

the nurse is caring for a client with hepatitis and is reviewing dietary instructions. the nurse instructs the client to have a diet that is a. low carbohydrate, high fat, and high protein b. high carbohydrate, low fat, and low protein c. low carbohydrate, low fat, and high protein d. high carbohydrate, low fat, and high protein

b. high carbohydrate, low fat, and low protein

the nurse is providing dietary instructions for a client who has chronic diverticulosis. which of the following should the nurse recommend? a. low residue b. high fiber c. low carbohydrate d. high protein

b. high fiber

the nurse is collecting data from a patient with liver failure to detect encephalopathy. what instructions should the nurse give to the patient to collect this data? a. stand with your eyes closed b. hold out your arms and hands and dorsiflex the wrist c. kneel on ypur hands and knees d. bear down as thought you were having a bowel movement

b. hold out your arms and hands and dorsiflex the wrist

the nurse is caring for a client admitted with acute pancreatitis. the client exhibits a positive trousseau's sign. muscle cramps. a positive chvostek's sign, and a prolonged QT interval on the ECG. the nurse knows that the most common electrolyte imbalance associated with pancreatitis is? a. hyperkalemia b. hypocalcemia c. hypercalcemia d. increased serum magnesium

b. hypocalcemia

the nurse is participating in a inservice on her unit. the inservice is on hepatitis. which of the following is correct about hepatitis and should be included in the inservice? a. the route of transmission for HAV is blood b. individuals with hepatitis are carriers and can spread the disease without showing any symptoms c. people with hepatitis may donate blood d. hepatitis does not need to be reported to the health department

b. individuals with hepatitis are carriers and can spread the disease without showing any symptoms

the nurse is caring for a client with cirrhosis. the client had blood work done and the nurse is reviewing the results. the nurse notices that the serum ammonia level is elevated. what should the nurse do? a. monitor for temperature elevation b. observe for increasing confusion c. measure the urine specific gravity d. restrict the intake of oral fluids

b. observe for increasing confusion

the nurse is preparing to administer pancrelipase (viokase) to a client who has pancreatitis. which of the following is an appropriate nursing action? a. administer the medication 30 min after a snack b. offer a glass of water following medication administration c. administer the medication 30 min before meals d. sprinkle the contents on peanut butter

b. offer a glass of water following medication administration

the nurse is assisting in developing a plan of care for a client admitted with cirrhosis. for which of the following would the nurse place the client on bleeding precautions? a. encephalopathy b. prolonged PT/INR c. elevated liver enzyme d. hepatorenal syndrome

b. prolonged PT/INR

the nurse caring for a client recently infected with hepatitis A. the nurse is reinforcing teaching on prevention of transmission of the virus. which of the following should be included? a. dont share razors with other individuals b. wash your hands after toileting c. cough and sneeze into tissue d. use spermicide during intercourse

b. wash your hands after toileting

a client who has a history of chronic biliary disease is admitted to the acute care facility with reports of anorexia, vomiting, chronic indigestion, and abdominal pain. the clients liver is enlarged and her abdomen's is distended. the client's liver enzymes are elevated. the client is diagnosed with cirrhosis of the liver. the nurse recognize which of the following as the cause of the client's enlarged and distended abdomen? a. asterixis b. paralytic ileus c. ascites d. hyperglycemic-hyperosmolar state

c. ascites

the nurse is providing care for a client admitted with cirrhosis. the client had lab results test done earlier that day and the nurse is reviewing the results. which lab if elevated is most indicative that the client may develop hepatic encephalopathy? a. serum creatine b. serum bilirubin c. blood ammonia d. blood urea nitrogen

c. blood ammonia

a client who has a small bowel obstruction secondary to abdominal adhesions from a previous surgery is admitted to the hospital. A nasogastric tube is inserted as a part of the treatment plan for the client. which of the following actions is appropriate for the nurse to take? a. subtract the NG drainage from the client's output b. irrigate the NG tube with 20 ml 0.9% sodium chloride every 8 hours c. check the client's abdomen for bowel movement d. provide oral care only twice day

c. check the client's abdomen for bowel movement

a client with a long history of ulcerative colitis has anemia. the nurse should explain to the that which of the following manifestations of colitis is likely to result in anemia? a. decreased iron in the client's diet b. intestinal malabsorption sundrome c. chronic blood loss d. intestinal parasites

c. chronic blood loss

the nurse is caring is caring for a pt with hepatic encephalopathy. which prescribed medicston should the nurse question before providing to this patient? a. vitamin k b. neomycin sulfate c. diazepam(valium) d. lactulose(cephulac)

c. diazepam(valium)

the nurse is reviewing the medical record of a client who has pancreatitis. the physical exam report by the provider indicates the presence of cullen's sign. which of the following is an appropriate action by the nurse to identify this finding? a. tap lightly at the costovertebral margin on the client's back b. palpate the client's right lower quadrant c. inspect the skin around the umbilicus d. auscultate the area below the client's scapula

c. inspect the skin around the umbilicus

Sulfasalazine(Azulfidine) has been prescribed to treat the client's exacerbation of Crohn's disease. which of the following statements should the nurse reinforce when explaining how to take the medication? a. take the medication 1 or 2 hrs after eating b. this medication may cause yellowing of the sclera c. notify the provider if sore throat or fever occur d. your stools may turn black in color

c. notify the provider if sore throat or fever occur

the nurse is caring for a client on the third day following abdominal surgery and assess the absence of bowel sounds, there is abdominal distention, and the client is not passing flatus. these findings indicate the client is experiencing a non-mechanical obstruction most likely due to? a. dietary imbalance b. fecal impaction c. paralytic ileus d. prolapsed incision

c. paralytic ileus

the nurse is reinforcing information on gallbladder disease with a new LPN. which of the following would be included? a. risk fasctors include low fat diet b. the cleint will experience sharp pain in the left upper quadrant c. the client may experience intense pain with nausea and vomiting after ingestion of a high fat meal d. elevated amylase can indicate common bile obstruction

c. the client may experience intense pain with nausea and vomiting after ingestion of a high fat meal

the nurse providing care for a client with an exacerbation of his ulcerative colitis. the client has been taking prednisone. which of the following findings is the priority? a. the client reports difficulty sleeping b. the blood glucose level at 8am is 140 mg/dl c. the client reports having a sore throat d. the client reports gaining 4 pounds in the last 6 months

c. the client reports having a sore throat

the nurse is monitoring a patient and finds a bulging area in the pt's groin. which additional finding should cause the nurse most concern? a. the bulging disappears at times b. the white blood cell count is 7,000/mm3 c. the patient develops pain at the site and vomiting d. the bulging occurs when the pt coughs or strains but dissapears when the client relaxes

c. the patient develops pain at the site and vomiting

a patient with cholelithiasis is having clay-colored stools. what should the nurse realize as the most common cause of clay-colored stools? a. retrograde bile flow into the liver b. accumulation of bile salts in the skin c. cirrhosis from chronic liver irritation d. a gallstone lodged in the common bile duct

d. a gallstone lodged in the common bile duct

the nurse is admitting a client who has pancreatitis. which of the following is an expected finding? a. pain in the right upper quadrant radiating to the right shoulder b. report of pain being worse when sitting upright c. pain relieved with defication d. epigastric pain that radiates to the left shoulder

d. epigastric pain that radiates to the left shoulder

the nurse is working in the emergency department and he is caring for a client admitted with a small bowel obstruction due to post surgical adhesions. what signs and symptoms would the nurse observe? a. minor fluid and electrolyte imbalance b. metabolic acidosis c. significant abdominal distention d. profuse projectile vomiting with a fecal odor

d. profuse projectile vomiting with a fecal odor

the nurse has been assigned a client with a large bowel obstruction. which finding would the nurse expect to find performing her assessment? a. severe fluid and electrolyte imbalance b. metabolic alkalosis c. profuse, sudden projectile vomiting d. significant abdominal distention

d. significant abdominal distention

a patient with acute pancrititis is experiencing severe pain. what position should the nurse encourage the patient to assume? a. lithotomy position b. prone with a pillow under the abdomen c. supine with legs elevated and head on a small pillow d. sitting in a chair leaning forward with a pillow for back support

d. sitting in a chair leaning forward with a pillow for back support

The nurse is reinforcing discharging instruction with a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria (lack of coordination), and sensory changes. Which of the following nursing statements are appropriate? wear an eye patch on the right eye at all times plan to relax in a hot tube spa each day engage in vigorous exercise program implement a schedule to include period of rest

implement a schedule to include period of rest

the nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from the client's nostril. The priority nursing action is to take the client's temperature place a moustache dressing under the nose notify the change nurse test the drainage for glucose

test the drainage for glucose