NDEE LECTURE PRACTICE EXAM

An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet would the nurse encourage the clinet to follow? A: Low-Fat B: High-Fiber C. High-Protein D. Low-Carbohydrate

B: High-Fiber Rationale: A high-fiber diet is recommended for diverticulosis. Fiber promotes passage of residue through the intestines, thereby preventing constipation. Constipation causes straining at stool; this increases intraluminal pressure, which can precipitate diverticulitis or perforation of diverticula. Low-fat, High-protein, & Low-Carbohydrate diets are not indicated for diverticulosis.

The nurse assesses a client with diagnosis of an intestinal obstruction in the descending colon. When auscultating the med-abdomen, which type of sound would the nurse expect to hear? A: Tympany B: Borborygmi C: Abdominal Bruit D: Pleural Friction Rub

B: Borborygmi Rationale: Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as a high-pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither type of bruit can be auscultated at the mid-abdomen, and neither type is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

The nurse is assessing female clients & identifies that which client has the greatest developing gallbladder disease? A: Older than age 40 and obese B: Older than age 40 with a low serum cholesterol level C: Less than age 40 years of age with a history of high fat intake D: Less than age 40 years of age with a family history of gallstones.

A: Older than age 40 and obese Rationale: The characteristics known as the 4Fs Female, Fat, Forty, Fertile are well-established risk factors for gallbladder disease. Gallbladder clients have an increase in serum cholesterol. A high fat intake does not predispose one to cholecystitis. Although there is an increased risk with family history of gallstones, gallbladder clients usually are older than the age of 40.

a client with cholecystitis is placed on low-fat, high-protein diet. which nutrient would the nurse teach the client to include in this diet? a. skim milk b. boiled beef c. poached eggs d. steamed broccoli

a. skim milk rationale: during acute cholecystitis, clients may have low-fat liquids; skim milk is low in fat & contains protein, which will promote healing. beef, even if it is lean, contains fat. egg yolks contain fat. although it is low in fat & contains protein, broccoli is gas-producing vegetable that should be avoided at this time.

which equipment would the nurse include when setting up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy? a. crash cart with bed board b. tracheostomy set & oxygen c. ampule of sodium bicarbonate d. airway & nonrebreather mask

b. tracheostomy set & oxygen rationale: a tracheostomy set & oxygen are necessary if the client experiences an acute respiratory obstruction as a result of postoperative edema, nerve damage, or tetany. A cardiac arrest is not an expected response after thyroid surgery. acidosis requiring sodium bicarbonate & cardiac arrest are not expected responses after a thyroidectomy. if the airway is obstructed by postoperative edema, the use of a mechanical airway will be ineffective bec it will not reach beyond the point of the obstruction. a nonrebreather mask is designed to deliver high concentration of oxygen. in the event of an airway obstruction, the client's need is to circumvent the obstruction, not deliver high concentration of oxygen.

the nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). which test result would confirm the diagnosis? a. digital rectal examination b. serum phosphatase level c. biopsy of prostatic tissue d. massage of prostatic fluid

c. biopsy of prostatic tissue rationale: a definitive diagnosis of the cellular changes associated with BPH is made by biopsy, with subsequent microscopic evaluation. palpation of the prostatic gland through the rectal examination is not a definitive diagnosis; this only reveals size & configuration of the prostate. the serum phosphatase level will provide information for prostate cancer, a definitive diagnosis cannot be made with this test for BPH. a sample of prostatic fluid helps diagnosis prostatitis.

which complication would the nurse monitor in a client with HYPERparathyroidism? a. tetany b. seizures c. bone pain d. graves disease

c. bone pain rationale: HYPERparathyroidism causes calcium release from the bones, leaving them porous, weak, & painful. Tetany is the result of LOW calcium levels; in this condition the serum calcium level increased. seizures are caused by increased neural activity, a condition not related to this disease. graves disease is the result of increased thyroid, not parathyroid, activity.

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. which response would the nurse provide? a. "You will have an abdominal incision and a dressing." b. "Your urine will be pink and free of clots." c."There will be an incision between your scrotum and rectum." d. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."

d. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place." rationale: the presence of an indwelling urinary catheter & a continuous irrigation are routine postoperative expectations after TURP; they provide for hemostasis & urinary excretion. an abdominal incision & dressing are present with a suprapubic, not transurethral, prostatectomy. after TURP, the client initially can expect hematuria & some blood clots; the continuous bladder irrigation keeps the bladder from of clots & the catheter patent. an incision between the scrotum & rectum is associated with a perineal prostatectomy, not a TURP

after an unsuccessful lithotripsy to break up renal calculi, a nephrolithotomy was successful in removing the client's renal calculi. which clinical indicator would the nurse monitor during the postoperative period & report immediately to the primary health care provider? a. continuous passage of pink-tinged urine b. pink drainage on the client's surgical dressing c. total intake volume of 2000 mL in 24 hours d. urinary output of 20 to 30 mL/h

d. urinary output of 20 to 30 mL/h rationale: the client's urinary output should be at least 30 mL/h; a decreased output may indicate obstruction, impaired kidney function, or fluid volume deficit. blood, tinting the urine pink, is expected. drainage on the surgical dressing may be pink; the nurse would report bright red drainage. the intake of 2000 mL in 24 hours is adequate; however, a higher intake usually is preferred to prevent fluid deficit (e.g., > 2000-3000 mL).

Which situation in a client with HYPERthyroidism may precipitate thyroid crisis (thyroid storm)? A: Increased iodine in the blood B: Removal of the parathyroid glands C: High levels of the hormone triiodothyronine (T3) D: Rebound increase in metabolism after anesthesia

C: High levels of the hormone triiodothyronine (T3) Rationale: Thyroid trauma, thyroid surgery, or physicological stress in a client with HYPERthyroidism may lead to a release of abnormally high levels of thyroid hormones. High levels of the hormone triiodothyronine (T3) intensify all the signs & symptoms of HYPERthyroidism (thyroid storm or crisis), such as increased temperature, pulse, & respirations, restlessness, vomiting, & often death. Iodine binds with thyroxine, thus decreasing the potential for crisis. Tetany, not thyroid crisis, occurs from surgical excision of the parathyroid glands. Anesthesia with depress metabolism, not increase it.

a client is diagnosed with a parathyroid dysfunction. which serum calcium concentration supports the diagnosis? a. 7.8 mg/dL b. 8.9 mg/dL c. 9.7 mg/dL d. 10.2 mg/dL

a. 7.8 mg/dL rationale: the normal serum calcium concentration ranges from 8.6 to 10.2 mg/dL. a serum calcium concentration below 8.6 mg/dL indicates HYPOcalcemia, & a serum calcium concentrations above 10.2 mg/dL indicates HYPERcalcemia. parathyroid hormones maintains calcium balance in the body. HYPOcalcemia reflects HYPOparathyroidism, & HYPERcalcemia suggests HYPERparathyroidism. the serum calcium concentration of 7.8 mg/dL is below the normal range & indicates HYPOcalcemia. therefore, the client may have HYPOparathyroidism, which is a parathyroid dysfunction. serum calcium concentrations 8.9 mg/dL, 9.7 mg/dL, & 10.2 mg/dL are all normal findings

list in the order of priority the techniques the nurse should use when assessing a child's abdomen with suspected appendicitis a. asking where it hurts b. warming the stethoscope's diaphragm c. assessing the abdomen by touch d. visually examining the abdomen e. auscultating for bowel sounds

a. asking where it hurts d. visually examining the abdomen b. warming the stethoscope's diaphragm e. auscultating for bowel sounds c. assessing the abdomen by touch rationale: asking the child where it hurts is the first step of the assessment; the answer may influence the subsequent assessment. inspection is the second part of the assessment; it involves observing the contour & symmetry of the abdomen. Warming the stethoscope's diaphragm before auscultation will help prevent tightening of the abdominal muscles. auscultation is the next part of the assessment; it involves listening for bowel sounds & recording them as present, hypoactive, hyperactive, or absent; it must be done before palpation bec touching the abdomen may alter the bowel sounds. palpation is the final component of an abdominal assessment.

laboratory reports reveal that the client's thyroxine (T4) levels are low. which medication might have led to this condition? a. lithium b. fluoxetine c. risperidone d. carbanmazpine

a. lithium rationale: lithium is used to treat bipolar disorder. decreased levels of thyroxine (T4) & triiodothyronine (T3) may indicate HYPOthyroidism. lithium may cause a goiter, which is associated with HYPOthyroidism. fluoxetine is a serotonin reuptake inhibitor that may leas to HYPOnatremia. risperidone is a second generation antipsychotic used to treat bipolar disorder that does not cause HYPOthyroids. carbamazepine is an antiepileptic medication used to treat bipolar disorder; this medication may cause leukopenia, anemia, & thrombocytopenia.

after a teaching session, the nurse evaluates the client's understanding of HYPOparathyroidism. which statement made by the client indicates the need for further education? a. 'I should eat an orange a day' b. 'I should include yogurt in my diet' c. I should perform mild exercises daily' d. ' I should sit outside in the sun'

b. 'I should include yogurt in my diet' rationale: further education is needed for the client. clients with HYPOparathyroidism have HYPOcalcemia. to replenish the calcium levels of the body, the clients should consume foods that are rich in calcium. however, foods rich in phosphorus such as yogurt, processed cheese, & milk should be avoided. all the other comments are correct & require no further educations by the nurse. oranges are good source of vitamin C & fibers. they help improve healing & remove wastes from the body. exercising is a good for overall health. sitting in the sun allows exposure of the client to sunlight, which is a natural source of vitamin D. vitamin D helps with absorption of calcium from the GI Tract.

the nurse is caring for a child who has renal calculi secondary to HYPERparathyroidism. which type of diet would the nurse teach the client? a. low purine b. low calcium c. high phosphorus d. high alkaline ash

b. low calcium rationale: a low calcium intake is recommended. calcium & phosphorus are components of these stones; food high in calcium & phosphorus should be avoided. low purine & high alkaline ash diets are indicated for clients with gout.

a client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. the client returns from surgery with a t-tube connected to a drainage bag. what would the nurse conclude is the purpose of the t-tube? a. decrease edema b. permit drainage of bile c. insert antibiotic medication d. provide for irrigation of the gallbladder

b. permit drainage of bile rationale: the t-tube provides a passageway for bile to move through the common bile duct in the presence of edema; it does not reduce edema. when the common bile duct is explored, the t-tube maintains patency until edema subsides. the t-tube will not reduce edema. antibiotics usually are not necessary postoperatively unless infected bile or pus is in the ducts (cholagnitis). the gallbladder has been excised & cannot be irrigated.

a client with irritable bowel syndrome has instructions to take psyllium for constipation. which statement is important for the nurse to include in the teaching plan? a. 'urine may be discolored.' b. 'stop taking the laxative once a bowel movement occurs.' c. 'each dose should be taken with a full glass of water or juice.' d. 'daily use may inhibit the absorption of some fat-soluble vitamins.'

c. 'each dose should be taken with a full glass of water or juice.' rationale: this bulk-forming laxative works by absorbing water into the intestine, which increases bulk & distends the bowel to initiate reflex bowel activity, thus promoting a bowel movement. a full glass of fluid taken at the same time will help minimize the risk of esophageal obstruction or fecal impaction. senna, a stimulant laxative, may cause urine discoloration. bulk-forming laxatives, such as psyllium, are the only laxative that are recommended for a long-term use, & in cases of irritable bowel syndrome; they are used to prevent constipation & should not be stopped once a bowel movement occurs. prolonged use of lubricant laxative, such as mineral oil, can inhibit the absorption of some fat-soluble vitamins.

which clinical manifestation would the nurse associate with benign prostatic hyperplasia? a. perineal edema b. urethral discharge c. flank pain radiating to the groin d. distention of the lower abdomen

d. distention of the lower abdomen rationale: distention of the suprapubic area indicates bladder is distended with urine & palpable. Perineal edema is not a clinical manifestation of urinary retention & benign prostatic hyperplasia. urethral discharge typically relates to sexually transmitted infections & may indicate an infection, but not benign prostatic hyperplasia. the discharge would be associated with a urinary infection. radiating flank pain may indicate renal calculi.

Assessment findings of a client who is admitted to the emergency department include cramping pain in the LLQ, weakness, bloating, malaise, & a low-grade fever. the nurse suspects which condition? a. pancreatitis b. appendicitis c. cholecystitis d. diverticulitis

d. diverticulitis rationale: although diverticula can occur at any point within the GI Tract, they are MOST common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the LLQ. Pancreatitis is associated with acute epigastric or LUQ pain. Appendicitis is associated with shifting of periumbilical pain to the RLQ & localizing at McBurney's point. Cholecystitis is associated with RUQ pain that may be referred to the right shoulder & scapula.

A primary health care provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings would the nurse expect when performing a health history and physical assessment? SATA A: Diarrhea with black feces B: Intolerance to foods high in fat C: Vomiting of coffee-ground emesis D: Gnawing pain when stomach is empty E: Pain that radiates to the right shoulder

B: Intolerance to foods high in fat E: Pain that radiates to the right shoulder Rationale: Interference with bile flow into the intestine will lead to an increasing inability to tolerate fatty foods. Although the gallbladder is in the URQ of the abdomen, when inflamed it can radiate to the right shoulder or scapula. Diarrhea with melena (black feces) is not associated with cholecystitis. Melena is tarry stools associated with upper GI bleeding; diarrhea is associated with increased with intestinal motility. Coffee-Ground emesis is indicative of gastric bleeding; it is not associated with cholecystitis. Gnawing pain when stomach is empty is associated with duodenal ulcers, not with cholecystitis

Which explanation would the nurse provide when responding to a client's inquiry about intussusception of the bowel? A: 'It is kinking of the bowel onto itself' B: 'it is a band of connective tissue compressing the bowel' C: 'It is telescoping of a proximal loop of bowel into a distal loop' D: 'It is a protrusion of an organ or part of an organ through the wall that contains it'

C: 'It is telescoping of a proximal loop of bowel into distal loop' Rationale: Intussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately connecting segment of the bowel. Volvulus is a twisting or kinking of the bowel onto itself. Adhesions are bands of scar tissue that can compress the bowel. Herniation describes protrusion of an organ through the wall that contains it.

A client is admitted with an acute onset of RLQ pain at McBurney point. Appendicitis is suspected. For which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis? A: Urinary retention B: Gastric hyperacidity C: Rebound tenderness D: Increased lower bowel motility

C: Rebound tenderness Rationale: Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute RLQ pain. Hyperacidity causes epigastric, not RLQ pain. There generally is decreased bowel motility distal to an inflamed appendix.

a self-help group of clients with irritable bowel syndrome has invited the nurse to present a program on nutrition. which substance would the nurse teach the clients to minimize in the diet to decrease GI irritability? a. cola drinks b. gelatin c. fiber d. rice

a. cola drinks rationale: the caffeine is cola is chemically irritating to the intestinal mucosa. caffeine also promotes secretion of gastric juices. gelatin is absorbed slowly & is not irritating. rice would not irritate the bowel & need not be restricted. fiber is increased in case of irritable bowel syndrome to provide bulk & regular bowel habits.

a client who is 5 feet 8 inches (173 cm) & weigh 220 lb (99.8 kg) has ureteral colic, blood in the urine, & blood pressure (BP) of 150/90 mm Hg. which objective is has the HIGHEST PRIORITY & directs the nursing intervention for this client? a. decrease pain b. decrease weight c. decrease hematuria d. decrease hypertension

a. decrease pain rationale: Ureteral colic clinical manifestation include sharp, severe pain (renal colic) radiating toward the genitalia & thigh. it is associated with ureteral distention & must be relieved. weight loss is a long-term goal; reducing pain is the priority. although hematuria is a concern & caused by the renal calculi, pain reduction is the priority. although the client's hypertension is a concern, pain reduction is priority. the BP will decrease with the reduction in the pain.

which intervention would prevent urinary stasis & formation of renal calculi in an immobile client? a. increasing oral fluids intake to 2 to 3 L/day b. maintaining bed rest after discharge c. limiting fluids intake to 1 L/day d. voiding at least every hour

a. increasing oral fluids intake to 2 to 3 L/day rationale: increasing oral fluids intake to 2 to 3 L/day, if not contraindicated, will dilute urine & promote urine flow, thus preventing stasis & complications such as renal calculi. bed rest & limited fluid intake may lead to urinary stasis & increase the risk for the formation of renal calculi. voiding at least every hour has no effect on urinary stasis & renal calculi.

the nurse is caring for a client who is experiencing an underproduction of thyroxine (T4). this condition is associated with which diagnosis? a. myxedema b. acromegaly c. graves disease d. cushing disease

a. myxedema rationale: myxedema is the severest form of HYPOthyroidism. decreased thyroid gland activity means reduced production of thyroid hormones. acromegaly results from excess growth hormones in adults once the epiphyses are closed. graves disease results from an excess, not a deficiency, of thyroid hormones. cushing disease results for excess glucocorticoids.

which complication would the nurse be concerned about if there is removal of the parathyroid glands during a thyroidectomy? a. tetany b. myxedema c. hypovolemic shock d. adrenocortical stimulation

a. tetany rationale: parathyroid removal eliminates the body's source of parathyroid hormone, which increases the blood calcium level. the resulting low body fluid calcium affects muscles resulting in tetany. loss of the thyroid gland will upset thyroid hormones balance & may cause myxedema. the parathyroids are not involving in regulating plasma volume; the pituitary gland & adrenal gland are responsible. the parathyroids do not regulate the adrenal glands.

the nurse identifies which clinical manifestations as being characteristic of HYPERthyroidism? SATA a: diaphoresis b: weight loss c: constipation d: protruding eyes e: cold intolerance

a: diaphoresis b: weight loss d: protruding eyes rationale: diaphoresis occurs with HYPERthyroidism bec of increased metabolism, resulting in hyperthermia. weight loss occurs with HYPERthyroidism bec of increased metabolism. bulging eyes occur with HYPERthyroidism & are thought to be related to an autoimmune response of the retroorbital tissue, which causes the eyeballs to enlarge & push forward. diarrhea, not constipation, occurs bec of increased body processes, specifically increased GI peristalsis. Heat intolerance, not cold intolerance, occurs bec of the increased metabolism associated with HYPERthyroidism.

the nurse is obtaining a health history from client with a diagnosis of peptic ulcer disease. the nurse identifies a possible contributory risk factor when the client makes which statement? a. 'my blood type is A positive' b. 'i smoke one pack of cigarettes a day' c. 'i have been overweight most of my life' d. 'my blood pressure has been high lately'

b. 'i smoke one pack of cigarettes a day' rationale: smoking cigarettes increases the acidity of GI secretions, which damages the mucosal lining. blood type O is more frequently associated with duodenal ulcer, but type A has no significance. being overweight is unrelated to peptic ulcer disease. high blood pressure is not directly related to peptic ulcer disease.

a 5-year old child complains of abdominal pain with nausea, anorexia, & a low-grade fever. palpation of the RLQ of the abdomen elicits pain. which condition would the nurse suspect? a. ulcerative colitis b. acute appendicitis c. hirchsprung disease d. hookworm infestation

b. acute appendicitis rationale: these are the classic signs & symptoms of acute appendicitis; they are caused by inflammation & altered GI functioning. the child will have diarrhea with ulcerative colitis. the child's adaptations do not indicate the constipation associated with Hirschsprung disease. the adaptations to hookworm infestation are anemia, malnutrition, & popular eruptions.

After reviewing the morning laboratory reports, which client would the nurse suspect as having peptic ulcer disease? a. haemophilus influenzae b. helicobacter pylori c. pseudomonas aeruginosa d. staphylococcus aureus

b. helicobacter pylori rationale: Helicobacter pylori (observed in client B) is a bacterium infecting the GI tract & causes peptic ulcers & gastritis. haemophilus influenzae (observed by client A) may cause nasopharyngitis, meningitis, or pneumonia. pseudomonas aeruginosa (observed by client C) may cause urinary tract infections & meningitis. staphylococcus aureus (observed in client D) may cause skin infections, pneumonia, urinary tract infections, acute osteomyelitis, & toxic shock syndrome

which condition would the nurse suspect in a 6-year-old child who was admitted with abdominal pain & guarding, nausea, anorexia, & pain with palpation of the RLQ? a. viral infection b. inflamed appendix c. irritable bowel d. parasitic infestation

b. inflamed appendix rationale: the child has classic signs & symptoms of appendicitis. the symptoms are caused by inflammation & altered GI function. the general symptoms may be seen in children with viral infections, irritable bowel, parasitic infestations. however, abdominal guarding & pain in the RLQ indicates a more specific condition, appendicitis

which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer? a. the pain intensifies after vomiting stomach content b. the pain occurs 1 to 2 hours after having a meal. c. the pain increases when ingesting an excess of fatty foods d. the pain begins in the epigastrium & radiates to the abdomen

b. the pain occurs 1 to 2 hours after having a meal. rationale: the pain occurs after the stomach empties; eating stimulates gastric secretions; which act on the gastric mucosa of an empty stomach, causing gnawing pain. vomiting temporarily alleviates pain because acid secretions are removed. there is no intolerance of fats, & eating generally alleviates pain. pain associated with the ingestion of fatty foods is associated with cholecystitis. pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated.

the nurse reviews the room assignments for clients who are scheduled for admission. one client is being hospitalized to receive intravenous steroids for management of crohn disease. the nurse would question the assignment if the client is schedule to have a roommate who has which illness? a. pancreatitis b. thrombophlebitis c. bacterial meningitis d. acute cholecystitis

c. bacterial meningitis rationale: the bacteria that cause meningitis are transmitted via air currents; the client with bacterial meningitis should be in a private room with airborne precautions to protect other people. pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

the nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, & afterward the client makes a list of foods that can be included int he diet. which food choices indicate that the teaching by the nurse is effective? SATA a. orange juice b. creamed soup c. jelly sandwich d. lean roast beef e. scrambled eggs

c. jelly sandwich d. lean roast beef e. scrambled eggs rationale: a jelly sandwich is low in residue & is less irritating to the colon than other foods. lean roast beef is low in residue & is less irritating to the colon than other foods. eggs are low in residue & are less irritating to the colon than other foods. orange juice contains cellulose (fiber), which is not absorbed & irritates the colon. milk is creamed soup contains lactose, which is irritating to the colon.

the nurse is caring for a client admitted with peritonitis. which finding in the medical record MOST likely the cause? a. gastritis b. hiatal hernia c. diverticulosis d. bowel obstruction

d. bowel obstruction rationale: causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis. gastritis & hiatal hernias do cause GI discomfort, but not peritonitis. inflammation of the diverticular pockets, diverticulitis, is a cause of peritonitis. diverticulosis is not an active inflammatory process.

during a home visit to a client, the nurse identifies tremors of the client's hands. when discussing this assessment, the client reports being nervous, having difficulty sleeping, & feeling as if the collars of shirts are getting tight. which additional assessment would the nurse report immediately to the health care provider? a. increased appetite b. recent weight loss c. feelings of warmth d. fluttering in the chest

d. fluttering in the chest rationale: many of these problems are associated with HYPERthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. the increases metabolism associated with HYPERthyroidism can lead to heart failure. although an increase appetite becomes a compensatory mechanism for the increase metabolism associated with HYPERthyroidism, it is not life threatening. although a feeling of warmth caused by the increased metabolism associated with HYPERthyroidism is uncomfortable, it is not life threatening.

a client experiences occasional RUQ pain attributed to cholecystitis. to prevent or minimize dyspepsia, the nurse would instruct the client to avoid which food items? a. nuts & popcorn b. meatloaf & baked potato c. chocolate & boiled shrimp d. fried chicken & buttered corn

d. fried chicken & buttered corn rationale: cholecystitis is often accompanied by intolerance to fatty foods, including fried foods & butter. nuts & popcorn have a high fiber content but have less fat than fried foods; nuts & popcorn cause flatulence & pain for clients with lower intestinal problems, such as diverticulosis. meatloaf & baked potato contains less fat than do fried foods & butter. Neither chocolate nor boiled seafood contains as much fat as fried chicken or butter

what factors may contribute to a client developing urinary calculi? a. increased fluid intake b. urine specific gravity of 1.017 c. jogging 3 miles (4.8 km) a day d. history of HYPERparathyroidism

d. history of HYPERparathyroidism rationale: HYPERparathyroidism results in high serum calcium levels; as the blood is filtered through the nephron, precipitates of calcium may form calculi. increased fluid intake will discourage stone formation by preventing stagnation of urine. a urine specific gravity of 1.017 is within the expected range of 1.010 to 1.030 & will not increase the risk of developing urinary calculi. a jogging schedule of 3 miles (4.8 km) daily reduces the risk of developing urinary calculi; activity improves glomerular filtration & inhibits calcium form leaving the bone.

After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. which nursing assessment helps confirm the diagnosis of intussusception? a. auscultating for bowel sounds b. listen for high-pitched crying c. measuring fluid intake & output d. observing characteristics of stools

d. observing characteristics of stools rationale: intussusception is a type of intestinal obstruction in which the intestine telescopes & becomes trapped within its lumen; the resulting stools are red & currant jelly-like due to the mixture of stool with blood & mucus. bowel sounds may not be significantly affected. High-pitched crying is a result of cerebral irritation; this is not expected with intussusception. accurate fluid intake & output records are important, but they are not essential to confirming this diagnosis.

Which manifestations of surgically induced HYPOthyroidism might the client exhibit after a thyroidectomy? SATA A: Fatigue B: Dry Skin C: Insomnia D: Excitability E: Weight Loss F: Intolerance to heat

A: Fatigue B: Dry Skin Rationale: Fatigue results from the decreased metabolic rate associated with HYPOthyroidism. Dry skin is caused by decreased glandular function. Insomnia is associated with HYPERthyroidism bec of the decreased metabolic rate. Weight gain, not loss, is associated with HYPOthyroidism bec of the decreased metabolic rate. Intolerance to heat is associated with HYPERthyroidism, not HYPOthyroidism.

A client is admitted to the hospital with a diagnosis of peptic ulcer. Which common complication would the nurse assess for in this client? A: Perforation B: Hemorrhage C: Pyloric obstruction D: Esophageal Varies

B: Hemorrhage Rationale: Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease. The complication of gastric perforation usually occurs after, and is not common as, hemorrhage. Pyloric obstruction is not a common complication of peptic ulcer disease. Esophageal varies occur with portal hypertension, not peptic ulcer disease.

an infant with congenital HYPOthyroidism receives levothyroxine for 3 months. which finding would indicate to the nurse that the medication is effective? a. the infant is alert & interactive b. the skin is cool to the touch c. the baby's fine tremor has ceased d. the baby's thyroid stimulating hormone level has increased

a. the infant is alert & interactive rationale: infants with congenital HYPOthyroidism are lethargic, & may even need to be awaken & stimulated to nurse; therefore an infant who is alert & interact appropriately for its age would demonstrate improvement. cool skin is a clinical sign of HYPOthyroidism related to slow basal metabolic rate. fine hand tremors is related to HYPERthyroidism & is not present in an infant with HYPOthyroidism, even one whose condition is being stabilized with levothyroxine. an increased thyroid stimulating hormone level would indicate inadequate treatment.

a client had been taking levothyroxine for HYPOthyroidism for 3 months. the nurse suspects that a decrease in dose is needed when the client exhibits which clinical manifestations? SATA a. tremors b. bradycardia c. somnolence d. heat intolerance e. decreased blood pressure

a. tremors d. heat intolerance rationale: excessive levothyroxine produces adaptation similar to HYPERthyroidism, including tremors, tachycardia, hypertension, heat intolerance, & insomnia. these adaptations are related to the increase in the metabolic rate associated with HYPERthyroidism. bradycardia is a sign of HYPOthyroidism & a need to increase the dose of levothyroxine. hypotension is a sign of HYPOthyroidism & a need to increase the dose of levothyroxine

the client asks the nurse to recommend foods that might be included in a diet for diverticular disease. which foods would be correct to include in the teaching plan? SATA a. whole grains b. cooked fruits & vegetables c. nuts & seeds d. lean red meats e. milk & eggs

a. whole grains b. cooked fruits & vegetables c. nuts & seeds e. milk & eggs rationale: with diverticular disease, the client should avoid food that may obstruct the diverticula; therefore the fiber should be digestible, such as whole grains & cooked fruits & vegetables. milk & eggs have no fiber content but are a good source of protein. although it had been believed in the past that avoiding nuts & seeds would prevent diverticulitis, there is no evidence to support this claim & nuts & seeds can be consumed as long as they are thoroughly chewed. for clients with diverticular disease, the client should decrease intake of fats & red meats.

when an intestinal obstruction is suspected, a client has a NG Tube inserted & attached to suction. which client response would the nurse critically assess? a. edema b. belching c. fluid deficit d. excessive salivation

c. fluid deficit rationale: dehydration is danger bec of fluid loss with GI suction. based on the data provided, edema , belching, & excessive salivation are not likely to occur.

a client complains of nocturia, bladder pain, urinary frequency, urgency, & dribbling at the end of urination. the digital rectal examination report indicates smooth, firm, & enlarged prostate tissue surround the urethra. which condition would the nurse suspect? a. prostatitis b. paraphimosis c. prostate cancer d. benign prostatic hyperplasia (BPH)

d. benign prostatic hyperplasia (BPH) rationale: BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth & overgrowth of prostate tissue surrounding the urethra. the clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. presence of fever, chills, back pain, & perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, & cloudy urine indicate prostatitis, which involves inflammation of the prostate gland. paraphimosis is a tightness of the penis foreskin that results in the inability to pull the skin forward from a retracted position & prevents normal return of the skin over the glans. symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, & leaking or dribbling

a client is admitted to the hospital with severe renal colic caused by a ureteral calculus. later that evening, the client's urinary output is much less than the intake. the client's bladder is not distended. which condition would the nurse suspect? a. oliguria b. hydroureter c. renal shutdown d. urethral obstruction

b. hydroureter rationale: calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the ureter, causing hydroureter. there is insufficient information to come to the conclusion of oliguria, even though output is less than intake; oliguria is present when the output is less than 400 mL in a. 24-hour period. calculi do not cause renal shutdown directly; they may obstruct the urinary tract & cause damage indirectly as a result of pressure from a urine buildup. if the urethra is obstructed, the bladder will be distended.

a client is admitted to the hospital with a diagnosis of intestinal obstruction & has an intestinal tube inserted. as prescribed, the nurse instills 30 mL of normal saline into the tube to maintain patency. which action would the nurse take next? a. add 30mL to the gastric output on the intake & output record b. record 30mL as intake in the intake & output record c. recognize that the amount instilled equals insensible losses d. identify that the amount is insignificant & does not need to be documented

b. record 30mL as intake in the intake & output record rationale: all fluids taken in by the client, regardless of the route, should be recorded on the intake & output record documentation indicates that the action was implemented. fluid instilled must be added to the intake record. the amount of gastric output needs to be accurate. no amount of fluid should be considered insignificant; insensible losses through the skin & lungs equal approximately 800mL daily. the health care provider's prescription indicates that the instillation is to be done as necessary; the total amount instilled during a 24-hour period may be significant. intake & output records should be accurate; therefore, every instillation should be documented

which serum blood level would the nurse expect to be decreased in a client with a diagnosis of HYPERthyroidism? a. calcium b. chloride c. phosphorus d. parathyroid hormones

c. phosphorus rationale: bec of its inverse relationship with calcium, when serum calcium levels increase, serum phosphorus levels decrease (greater than 3 mg/dL; greater than 0.17 mmol/L). serum calcium levels will increase bec of the action of elevated levels of serum parathormone; serum calcium levels usually exceed 10 mg/dL (2.50 mmol/L). serum chloride level will increase, not decrease, with HYPERthyroidism. Parathyroid hormone, produced in the parathyroid gland, will increase with HYPERparathyroidism.