NCLEX 10,000 nsg 210 test 2
8. Which nursing diagnosis is most appropriate for a client with Addison's disease? a.Risk for infection b.Fluid volume excess c.Urinary retention d.Hypothermia
A. Addison's disease is also known asAdrenal insufficiency. There'sinsufficient adrenocorticotropichormone (ACTH) production whichincludes epinephrine andnorepinephrine that are helpful in theflight and fight response. If the body isunable to fight off stressors, this willlead to body exhaustion and increasesusceptibility to illnesses
12. Which outcome indicates that treatment for diabetes insipidus is effective a. fluid intake of less than 2500 ml in24 hours b.Urine output of more than 200ml/hr c.Blood p ressure of 90/50 d.Pulse rate of 126 beats/min
A. DI is characterized by inadequateantidiuretic hormone leading toexcessive loss of Na and H20 followedby hypotension and tachycardia. Tachycardia is a compensatorymechanism in an effort to pump moreblood d/t the decreasing circulatingfluid. It is important to increase thefluid intake to prevent hypovolemicshock
28.A client has been diagnosed with type1 insulin dependent DM. which client's comment correlates best with this disorder? a.I was thirsty all the time. I just couldn't get enough to drink b.It seemed like I had no appetite. I had to get myself eat c.I had cough and cold that just didn't seem to go away d.I noticed a pain when I went to the bathroom
A. DM type 1 is a decreased in insulinproduction leading to increasingamount of glucose in the blood.Hyperglycemia causes osmoticdiuresis that leads to frequenturination and leads to dehydration
34.A client is recovering from ileostomy that was performed to treat inflammatory bowel disease. During the teaching discharge, the nurse should stress: a.Increasing fluid intake to prevent dehydration b.Wearing appliance pouch only at bedtime c.Consuming a high protein , highfiber diet d.Taking only enteric medications
A. ileostomy is bringing out the ileumwhich is the end of the small intestineinto an opening on the abdomen. Oneimportant function of the colon iswater absroption, since water is notanymore pass through the colon ,most fluid is lost into the pouch ratherthan being absorb making the clientmore prone to dehydration. Pouchshould be worn all the time. Low fiberdiet should be advised postoperativelybecause surgery causes the bowel toswell making digestion of fiberdifficult. Once the swelling hassubsided(usually after 8 wks) thepatient can resume a normal die
21.A client is being returned to the room after subtotal thyroidectomy. Whichpiece of equipment is important to the nurse to bring to the client's bedside? a.Indwelling foley catheter kit b.Tracheostomy set c.Cardiac monitor d.Humidifier
B. Bleeding / hematoma is a lifethreatening complication thatobstructs airway postthyroidectomy. Tracheostomy set should be at thebedside to establish airwayimmediately if respiratory distressoccurs
9. Which of these signs suggest that a client with Symptom if Inappropriate Antidiuretic Hormone(SIADH) has developed complications? a.Titanic contractions b.Neck vein distention c.Weight loss d.Polyuria
B. antidiuretic hormone(ADH) preventsdiuresis or urination. Excessive ADHleads to excess Na and H2O retentionthereby gaining weight. Increasedamount of fluid in the blood vesselscauses increased venous return andfluid overload. Chronic condition maylead to congestive heart failure inwhich distended neck vein is one of the sign
5. The nurse is assessing a client with Cushing's disease. Which observation should be reported to the physician immediately. a.Pitting edema of the legs b.Irregular apical pulse c.Dry mucous membrane d.Frequent urination
B. cushing's disease is an excessive production of mineralocorticoids( aldosterone- forsodium and water reabsorption),glucocorticoids( cortisol- breakdown of fats and protein and gluconeogenesis) and androgens (masculine hormone. Although a pitting edema is a characteristic symptom of cushing disease because of excessive water and sodium reabsorption, it is not an emergency condition. Irregular apical pulse is the primary concern and should be reported immediately
17. The nurse should expect a client with hypothyroidism to report which of these health concerns? a.Increased appetite and weight loss b.Puffiness of the face and hands c.Nervousness and tremors d.Increasing exophthalmos
B. thyroid hormones are responsiblefor many metabolic processes. OptionsA,C,D are result of hyperthyroidism d/tincreased metabolism andneuromuscular hyperactivity. Onefunction of thyroid hormone is proteinsynthesis which maintain osmoticpressure in the blood vessels . if protein concentration in the vessels isdecreased,there's a fluid shift into theextracellular space leading to edema
18 A client with hypothyroidism is receiving levothyroxine sodium (synthroid), 50 mcg. P.O daily.Which of these findings should the nurse recognize as an adverse effect? a.Dysuria b.Leg cramps c.Tachycardia d.Blurred vision
C. synthroid adverse effects typicallyresulted from overdose
A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When she informs him that the physician has ordered a wound care nurse to examine his foot, the client asks why he should see anyone other than this nurse. He states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." What is the nurse's best response? a) "We're very concerned about your foot and we want to provide the best possible care for you." b) "This is a big deal and you need to recognize how serious it is." c) "This is the physician's recommendation. The wound care nurse will see you today." d) "You could lose your foot if you don't see the wound care nurse."
a - The client's response indicates that he's in denial and needs further insight and education about his condition. Letting the client know that the nurse has his best interests in mind helps him accept the wound-care nurse. Although telling the client that his condition is serious and that the wound care nurse will see him that day are true statements, they're much too direct and may increase client resistance. Telling the client he could lose his foot is inappropriate and isn't therapeutic communication.
A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery? a. administer half of the client's typical morning insulin dose as ordered b. administer an oral antidiabeteic agent as ordered c. administer an I.V. insulin infusion as ordered d. administer the client's normal daily dose of insulin as ordered
a - if the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: a. perform the procedure safely and correctly b. critique the nurse's performance of the procedure c. explain all of the steps of the procedure correctly d. correctly answer a post-test about the procedure
a - the nurse should judge that learning has occurred from evidence of a change I the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates of knowledge at the cognitive level only. A post-test does not indicate the degree to which the client has learned a psychomotor skill.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? a) Moist mucous membranes. b) Passage of a soft, formed stool. c) Absence of diarrhea for a 4-hour period. d) Ability to tolerate intravenous fluids well.
a) CORRECT ANSWER Moist mucous membranes. Reason: The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? a) Protects the client's right to self-determination in health care decision making. b) Helps the client refuse treatment that he or she does not wish to undergo. c) Helps the client to make a living will regarding future health care required. d) Provides the client with in-depth knowledge about the treatment options available.
a) CORRECT ANSWER Protects the client's right to self-determination in health care decision making. Reason: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery? a) Peritonitis. b) Thrombophlebitis. c) Ascites. d) Inguinal hernia.
b - After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.
A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a) "Do you have the pain all the time?" b) "Can you describe the pain?" c) "Where does it hurt the most?" d) "Is the pain stabbing like a knife?"
b - Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response.
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? a. "I can still eat my favorite salty foods." b. "when my moods fluctuate, I'll increase my dose of lithium." c. "a good blood level of the drug means the drug concentration has stabilized." d. "eating too much watermelon will affect my lithium level."
b - a client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice and cranberry juice.
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? a) "I'll increase my intake of protein during exacerbations." b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."
b) CORRECT ANSWER "I should increase my intake of fresh fruits and vegetables during remissions." Reason: A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a. keep their home warmer than usual b. encourage plenty of outdoor activities c. promote interactions with one friend instead of groups d. limit bathing to prevent skin irritation
c - children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend's is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.
Which of the following laboratory findings are expected when a client has diverticulitis? a) Elevated red blood cell count. b) Decreased platelet count. c) Elevated white blood cell count. d) Elevated serum blood urea nitrogen concentration.
c) CORRECT ANSWER Elevated white blood cell count. Reason: Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a) Hyperalbuminemia. b) Thrombocytopenia. c) Hypokalemia. d) Hypercalcemia.
c) CORRECT ANSWER Hypokalemia. Reason: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.
Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids? a) Decrease fiber in the diet. b) Take laxatives to promote bowel movements. c) Use warm sitz baths. d) Decrease physical activity.
c) CORRECT ANSWER Use warm sitz baths. Reason: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.
A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter? a) Family history of pressure ulcers b) Presence of pressure ulcers on the client c) Potential areas of pressure ulcer development d) Overall risk of developing pressure ulcers
d) CORRECT ANSWER Overall risk of developing pressure ulcers Reason: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
