MS 2
An adult develops diarrhea secondary to hyperosmolar enteral therapy. The care plan now includes giving the client water every 4 to 6 hours and after feedings. Which of the following findings would indicate that fluid therapy was effective? A. Dry mucous membranes B. Hyperactive bowel sounds C. Increased urinary output D. Hypokalemia
C
Which of the following types of diabetes is controlled primarily through diet, exercise, and oral antidiabetic agents? A. Diabetes Insipidus B. Diabetic Ketoacidosis C. Type 1 Diabetes Mellitus D. Type 2 Diabetes Mellitus
D
A client has recently been diagnosed with peptic ulcer disease. Diagnostic studies confirm the presence of the gram-negative bacteria Helicobacter pylori in his G.IT. If the client has a duodenal ulcer, how would the nurse expect the "ulcer pain" to be described by the client? A. Located in the upper right epigastric area radiating to his right shoulder or back. B. Relieved by vomiting C. Occurring 2 to 3 hours after a meal , often awakening him between 1:00 and 2:00 AM. D. Worsening with the ingestion of food.
A
Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.
A
When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: A. Iliac area B. Epigastric area C. Hypogastric area D. Suprasternal area
B
A client who has had a gastric ulcer asks what to do if the epigastric pain occurs. The nurse would know that the teaching was effective when the client states, "I will: A. Increase my food intake." B. Take the aspirin with milk." C. Eliminate fluids with meals." D. Take the antacid preparation."
D
While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration.
D
A client has a history of Peptic ulcer disease. He has had numerous bleeding episodes in the past and is admitted to the hospital for evaluation. His physician has prescribed Cimetidine (Tagamet). What is the primary reason for the client to take Tagamet? A. Blocks the secretion of gastric hydrochloric acid. B. Coats the gastric mucosa with a protective membrane. C. Increases the sensitivity of H2 receptors. D. Releases basal gastric acid.
A
A client is suspected of having a peptic ulcer. When obtaining a history from this client, the nurse would expect the reported pain to: A. Intensify when the client vomits. B. Occur one to three hours after meals. C. Increase when the client eats fatty foods. D. Begin in the epigastrium and radiate across the
A
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake
A
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply. A. Acute Pain Related to Increased Peristalsis and GI Inflammation B. Activity Intolerance Related to Generalized Weakness C. Bowel Incontinence Related to Increased Intestinal Peristalsis D. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E. Impaired Urinary Elimination Related to Gl Pressure on the Bladder
A,B,D
A client was admitted to the hospital because of transient ischemic attack secondary to atrial fibrillation. He would be given which of the following medications to prevent further neurologic deficit? A. Heparin B. Digoxin C. Diltiazem D. Quinidine Gluconate
A
A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse should assess the client for esophageal perforation, which is indicated by: A. Faintness and feelings of fullness. B. Diaphoresis and cardiac palpitations C. Elevated heart rate and abdominal pain D. Increased blood pressure and urinary output
A
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? A. "You may have difficulty believing this, but the paralysis caused by this disease is temporary. B. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." C. "It must be hard to accept the permanency of your paralysis." D. "You'll first regain use of your legs and then your arms.
A
A male client with Bell's Palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem. B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia. C. Primary genetic in origin, triggered by exposure to meningitis. D. Primarily genetic in origin, triggered by exposure to neurotoxins.
A
For a client with a stroke, which of the following criteria must be fulfilled before the client is fed? A. The gag reflex returns. B. Speech returns to normal. C. Cranial nerves III, IV, and VI are intact. D. The client swallow small sips of water without coughing.
A
Which of the following symptoms is the chief sign of hypoparathyroidism? A. Tetany B.Chest pain C. Exophthalmos D.Shortness of breath
A
A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunization B. Use of standard precautions C. Consumption of a vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections
A,B
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B. Administer phenytoin (Dilantin) 200 mg PO daily. C. Teach the patient about the need for good oral hygiene. D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
B
A client comes to the emergency department after hitting his head in a motor vehicle accident. He's alert and oriented. Which of the following nursing interventions should be done first? A. Call for an immediate chest X-ray. B. Immobilize the client's head and neck. C. Open the airway with the head-tilt chin-lift maneuver. D. Assess full range of motion (ROM) to determine the extent of injuries.
B
A client has a fecal impaction. The physician orders an oil retention enema followed by a cleansing enema. What is the reason for administering an oil-retention enema to the client? A. Lubricate the walls of the intestinal tract. B. Soften the fecal mass and lubricate the walls of the rectum and colon. C. Reduce the bacterial content of the fecal mass. D. Coat the walls of the intestines to prevent irritation by the hardened fecal mass.
B
A client is scheduled for a barium swallow: the nurse should: A. Ask the client about allergies to iodine. B. Ensure a laxative is ordered after the test. C. Give only clear fluids on the day of the test. D. Administer cleansing enemas before the test.
B
A client presents with diaphoresis, palpitations, and tachycardia approximately 1 ½ hour after taking his regular morning insulin. Which of the following treatments is appropriate for this client? A. Check pulse oximetry and administer oxygen therapy. B. Check blood glucose level and administer carbohydrates. C. Give nitroglycerin and perform an electrocardiogram (ECG). D. Restrict salt, administer diuretics, and perform a paracentesis.
B
The nurse is performing an admission assessment on a client with a diagnosis of a detached retina. Which of the following is associated with this eye disorder? A. Pain in the affected eye. B. Total loss of vision. C. A sense of a curtain falling across the field of vision. D. A yellow discoloration of the sclera.
C
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is A. Eve pain B. Floating spots C. Blurred vision D. Diplopia
C
Objectives for treating diabetic ketoacidosis (DKA) include administration of which of the following treatments? A. Glucagon B. Blood products C. Glucocorticoids D. Insulin and I.V. fluids
D
A man is admitted with bleeding varices. A Sengstaken -Blakemore tube is inserted in an effort to stop the bleeding. After the Sengstaken-Blakemore tube is inserted, the client has difficulty breathing. Based on this information, what is the first action the nurse should take? A. Deflate the esophageal balloon. B. Encourage him to take deep breaths. C. Monitor his vital signs. D. Notify the physician.
A
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A. Document the presence of normal bile output. B. Irrigate the drainage system with normal saline as ordered. C. Aspirate a sample of the drainage for culture. D. Promptly report this assessment finding to the primary care provider.
A
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. AsterixIs B. Constructional apraxia C. Fetor hepaticus D. Palmar erythema
A
A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patient's care, the nurse should collaborate with the patient and prioritize what goal? A. Patient will accurately identify foods that trigger symptoms. B. Patient will demonstrate appropriate care of his ileostomy. C. Patient will demonstrate appropriate use of standard infection control precautions. D. Patient will adhere to recommended guidelines for mobility and activity.
A
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times dailv. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to 3 soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool
A
A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A. Risk for Infection Related to Immunosuppressant Use B. Risk for Injury Related to Decreased Hemostasis C. Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis D. Risk for Contamination Related to Accumulation of Ammonia
A
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A. Position the patient on the right side with a pillow under the costal margin after the procedure. B. Administer 1 unit of albumin 90 minutes before the procedure as ordered C. Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure. D. Confirm that the patient's electrolyte levels have been assessed prior to the procedure.
A
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A. How many alcoholic drinks do you typically consume in a week? B. To the best of your knowledge, are your immunizations up to date? C. Have you ever worked in an occupation where you might have been exposed to toxins? D. Has anyone in your family ever experienced symptoms similar to yours?
A
After an acute episode of Upper G.I. bleeding, a client vomits undigested antacids and complains of severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the physician, the nurse should: A. Keep the client NPO in preparation for surgery. B. Start oxygen per nasal cannula at 3 to 4 liters per minute. C. Place the client in the supine position with the legs elevated. D. Ask the client whether any red or black stools have been noted.
A
The client with glaucoma asks the nurse if complete vision will return. The most appropriate response is: A. "Although some vision has been lost and cannot be restored, a further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work." C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks."
A
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles
A
The nurse is caring for a client with a diagnosis of a detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? A. Complaints of a burst of black spots or floaters. B. A sudden sharp pain in the eye. C. Total loss of vision. D. A reddened conjunctiva.
A
When caring for a client with spinal cord injury who has quadriplegia, which of the following nursing interventions takes priority? A. Preventing atelectasis. B. Maintaining skin integrity. C. Forcing fluids to prevent renal calculi. D. Obtaining adaptive devices for more independence.
A
When performing the initial history and physical examination of a client with tentative diagnosis of peptic ulcer, the nurse would expect the client to describe the pain as: A. Gnawing epigastric pain or boring pain in the back. B. Located in the right shoulder and preceded by nausea. C. Sudden, sharp abdominal pain, increasing in intensity. D. Heartburn and substernal discomfort when lying down.
A
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Schedule intermittent catheterization every 2 to 4 hours. B. Insert an indwelling urinary catheter to straight drainage. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.
A
Which of the following laboratory results supports a diagnosis of primary hyperparathyroidism? A. High parathyroid hormone and high calcium levels B. High magnesium and high thyroid hormone levels C. Low parathyroid hormone and low potassium levels D. Low thyroid-stimulating hormone (TSH) and high phosphorous levels
A
Which of the following nursing interventions takes priority for the client having a tonicconic seizure? A. Maintaining a patent airway. B. Timing the duration of the seizure. C. Noting the origin of seizure activity. D. Inserting a padded tongue blade to prevent the client from biting his tongue.
A
A client with Meniere's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling vertigo? A. Increase fluid intake to 3000 ml a day. B. Avoid sudden head movements. C. Lie still and watch the television. D. Increase sodium in the diet.
B
A client with hyperthyroidism asks the nurse why he must take beta-adrenergic blockers. Which statement correctly describes the purpose of beta-blockers for this client? A. "Beta-adrenergic blockers reduce blood pressure." B. "Beta-adrenergic blockers protect the heart from damage." C. "Beta-adrenergic blockers slow the growth of the thyroid." D. "Beta-adrenergic blockers will eliminate your headaches.
B
A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station. B. An isolation room three doors from the nurses' station. C. A semi-private room with a 32-year-old client who has viral meningitis. D. A two-bedroom with a client who previously had bacterial meningitis.
B
A male client is color blind. The nurse understands that this client has a problem with: A. Rods B. Cones C. Lens D. Aqueous humor
B
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Waterv, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition
B
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the patient to conduct online research into colostomies. B. Engage the patient in the care of the ostomy to the extent that the patient is willing. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.
B
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptom resolution. B. Adhere to dosing recommendations of OTC analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.
B
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D. Spontaneous
B
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.
B
Because of chronic crampy pain, diarrhea and cachecia, a young adult is to receive Total Parenteral Nutrition (TPN) via a central line. Before preparing the client for the insertion of the catheter, the nurse should understand that: A. There will be a moderate amount of pain. B. The feeding will be administered intermittently. C. Fluoroscopy must be done before TPN is started. D. The jugular vein is the most commonly used insertion site.
B
The nurse is reviewing the physician's orders for a client with Meniere's disease. Which diet will most likely be prescribed? A. Low-cholesterol diet B. Low-sodium diet C. Low-carbohydrate diet D. Low-fat diet
B
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: A. Take a hot bath. B. Rest in an air-conditioned room. C. Increase the dose of muscle relaxants. D. Avoid naps during the day.
B
The nurse understands the rationale of rotating the injection site, if he says: A. "It prevents insulin edema. B. "It prevents insulin lipodystrophy." C. "It prevents insulin resistance." D. "It prevents systemic allergic reactions."
B
Which of the following conditions is a risk factor for hemorrhagic stroke? A. Diabetes B. Hypertension C. Recent viral infection D. Coronary artery disease
B
. A client with C6 spinal cord injury would most likely have which of the following symptoms? A. Aphasia B. Paraplegia C. Tetraplegia D. Hemiparesis
C
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise. B. Taking excess medication C. Omitting doses of medication. D. Increasing intake of fatty foods.
C
A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss B. Vertigo, vomiting, and nystagmus C. Vertigo, pain, and hearing impairment D. Vertigo, blurred vision, and fever
C
A female client, who has a hiatal hernia asks the nurse how to best prevent esophageal reflux. The nurse's best response would be: A. "Increase your intake of fat with each meal." B. "Lie down after eating to help your digestion." C."Reduce your caloric intake to foster weight reduction." D. "Drink several glasses of fluid during each of your meals."
C
A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half-circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage
C
A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? A. Infusing I.V. fluids rapidly as ordered B. Encouraging increased oral intake C. Restricting fluids D. Administering glucose-containing I.V. fluids as ordered
C
A male client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. When obtaining this client's history, the nurse should give priority to the client's statement that: A. His pain is increased after meals. B. He experiences nausea frequently. C. His stools have a tarry appearance. D. He recently joined Alcoholics Anonymous
C
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degrees to right side of the abdomen and push down firmly.
C
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The patient will obtain measurement of drainage from the T-tube. B. The patient will exercise three times a week. C. The patient will take immunosuppressive agents as required. D. The patient will monitor for signs of liver dysfunction.
C
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h
C
A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather that ulcerative colitis, as the cause of the patient's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa
C
A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60.mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury
C
An adult has a Billroth I procedure and does well post-operatively. The nürse knows the client understands discharge teaching when the client recognizes that the symptoms of dizziness, sweating and weakness in the weeks following surgery are usually associated with what condition? A. Afferent loop syndrome B. Pernicious anemia C. Dumping syndrome D. Marginal ulcers
C
An adult is 8 hours post- op a Billroth I (gastric resection) for a gastric ulcer. The drainage from his nasogastric decompression tube is thickened and the volume of secretions has dramatically reduced in the last2 hours. The client complains that he feels like he is going to vomit. What is the most appropriate nursing action? A. Reposition the nasogastric tube by advancing t gently. B. Notify the physician of your findings. C. Irrigate the nasogastric tube with 50 ml. of sterile normal D. Discontinue the low-intermittent suctioning.
C
Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop stress Curling's ulcer. The nurse should know that stress ulcers usually are evidenced by: A. Unexplained shock B. Melena for several davs C. Sudden massive hemorrhage D. A gradual drop in the hematocrit value
C
Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A. Cryosurgery B. Liver transplantation C. Lobectomy D. Laser hyperthermia
C
During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: A. A normal finding. B. A conductive hearing loss in the right ear. C. A sensorineural or conductive loss. D. The presence of nystagmus
C
The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? A. Self-care deficit B. Imbalanced nutrition C. Disturbed sensory perception D. Anxiety
C
When assessing vital signs in a client with a seizure disorder, which of the following measures is used? A. Checking for pulse deficit. B. Checking for pulsus paradoxus. C. Taking an axillary instead of oral temperatures. D. Checking the blood pressure for an auscultatory gap.
C
Which of the following diets would be least likely to lead to aspiration in a client who had a stroke with residual dysphagia? A. Full liquid B. Clear liquid C. Mechanical soft D. Thickened liquid
C
Which of the following disease processes is caused by an absence of insulin or inadequate amount of insulin, resulting in hyperglycemia and leading to a series of biochemical disorders? A. Diabetes insipidus B. Hyperaldosteronism C. Diabetic ketoacidosis D. Gestational diabetes
C
Which of the following nursing intervention should be performed for a client with Cushing's syndrome? a. Suggest clothing or bedding that is cool and comfortable b. Suggest consumption of highly carbohydrate and low-protein foods C. Explain that physical changes are a result of excessive corticosteroids, d. Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather.
C
Which of the following outcomes are expected for a client being treated for Addison's disease? A. Avoiding alcohol to decrease abdominal girth B. Avoiding hot and uncomfortable environments C. Reporting absence of postural hypotension symptoms D. Selecting and eating food high in protein, calcium, and vitamin D
C
Which of the following signs and symptoms of increased intracranial pressure (ICP) after head trauma would appear first? A. Bradycardia B. Widened pulse pressure C. Restlessness and confusion D. Large amounts of very diluted urine
C
A 50-year-old executive reports a loss of 20 pounds in three months. The stools are black and tarry, and the physician schedules a colonoscopy. The nurse should prepare the client for the test by: A. Administering an oil retention enema just before the test. B. Instructing that a bland diet be eaten the night before the test. C. Explaining that the pretest cathartic will cause diarrhea after the test. D. Advising the client not to eat or drink anything the morning of the test.
D
A 79-year-old client is admitted to the hospital with painful abdominal spasms and severe diarrhea of two days duration. The order of assessment the nurse should follow when performing an admitting examination of this client should be: A. Inspection, Percussion, Palpation, Auscultation B. Inspection, Palpation, Auscultation, Percussion C. Inspection, Palpation, Percussion, Auscultation D. Inspection, auscultation, percussion, palpation
D
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection
D
A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours. C. "Shampoo your hair every day for ten (10) days to help prevent ear infection. D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
D
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K
D
A nurse is participating in the emergency catchatgatient who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide (Sandostatin)
D
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver
D
A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopies B. Adherence to recommended immunization schedules C. Reqular blood pressure monitoring D. Frequent screening for osteoporosis
D
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A."Watch him for keyhole pupil for the next 24 hours." B. "Expect profuse vomiting for 24 hours after the iniury." C. "Notify the physician immediately if he has a headache." D. "Wake him every hour and assess his orientation to person, time, and place."
D
An elderly client complains of frequent episodes of constipation. What is an effective strategy for preventing constipation? A. Reducing fluid intake to encourage bulk formation in the intestinal lumen. B. Use of laxatives daily to establish a regular elimination pattern. C. A regimen of exercises directed at toning the abdominal muscles. D. Setting a routine for bowel elimination just before bedtime.
D
If fluid intake is limited in a client with diabetes insipidus, which of the following complications will he be at risk for developing? A. Hypertension and bradycardia B. Glucosuria and wight gain C. Peripheral edema and hyperglycemia D. Severe dehydration and hypernatremia
D
Rose is seeking consultation at Dr. Anthony's clinic for physical complains. The physician has noted possible diagnosis of hypothyroidism. Which of the following symptoms are present in hypothyroidism? A. Polyuria, polydipsia, and weight loss B. Heat intolerance, nervousness, weight loss, and hair loss C. Coarsening of facial features and extremity enlargement D. Tiredness, cold intolerance, weight gain, and constipation
D
The nurse caring for a client at night insists that the client cannot tolerate the ordered intermittent tube feedings. The primary nurse should first: A. Suggest that an antiemetic be prescribed. B. Change the feeding schedule to omit nights. C. Request that the type of solution be changed. D. Gather more data from the night nurse about the technique used.
D
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals. B. Doing muscle-strengthening exercises. C. Doing all chores early in the day while less fatigued. D. Taking medications on time to maintain therapeutic blood levels.
D
The nurse should teach the client with Gastroesophageal reflux disease that after meals the client should: A. Take a short walk. B. Drink 8 ounces of water. C. Lie down for at least 20 minutes D. Rest in a sitting position for one-half hour.
D
The physician orders Total Parenteral Nutrition 1 liter every 12 hours. The primary nursing responsibility should be to monitor the client's: A. Electrolytes B. Urinary output C. Administration rate D. Serum glucose levels
D
When planning a client to go home with Total Parenteral Nutrition, the nurse should help the client plan: A. Which days will be used for administration. B. For daily insertion of the circulatory access. C. For professional help to administer the TPN. D. A schedule of administration around regular activity.
D
Which of the following instruments is used to record intraocular pressure? A. Goniometer B. Ophthalmoscope C. Slit lamp D. Tonometer
D