NUR 303 Quiz 3 ATI
A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A) "I will wear gloves while changing the pet litter box." B) "I will rinse raw fruits with water before eating them." C) "I will wear a mask when around family members who are ill." D) "I will cook vegetables before eating them."
Rationale: A) A client who has AIDS should avoid changing the litter box to prevent acquiring toxoplasmosis. B) A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C) Due to compromised immune response, a client who has AIDS should avoid contact with family members who are ill. D) CORRECT: A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A) Pain in the right upper quadrant radiating to right shoulder. B) Report of pain being worse when sitting upright. C) Pain relieved with defecation. D) Epigastric pain radiating to the left shoulder.
Rationale: A) A client who has cholecystitis will report pain in the right upper quadrant radiating to the right shoulder. B) A client who has pancreatitis will report pain being worse when lying down. C) A client who has pancreatitis will report that pain is relieved by assuming the fetal position. D) CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A) "I can drink up to 2 quarts of fluid a day." B) "I will need to use insulin to control my blood glucose levels." C) "I should expect to gain weight during this illness." D) "I might experience confusion or balance problems."
Rationale: A) Excessive thirst is a manifestation of diabetes insipidus. Consumption of 4 to 30 L/day can be expected, and fluid intake should not be limited. B) Elevated blood glucose levels are a manifestation of diabetes mellitus. C) Weight loss is a manifestation of diabetes insipidus. D) CORRECT: Confusion and ataxia are findings associated with DI.
A nurse in a clinic is caring for a client who is to receive an immunization. The client asks about contraindications to immunizations. Which of the following responses should the nurse make? A) "The use of insulin is a contraindication." B) "An anaphylactic reaction is a contraindication for administration of any type of immunization." C) "The common cold is a contraindication for receiving an immunization." D) "Your provider will weigh the risks if you have experienced any adverse effects."
Rationale: A) A client who takes insulin is able to receive immunizations unless other contraindications are present. B) The client who has experienced an anaphylactic reaction can receive other immunizations that contain different substances. C) The client who has a common cold can receive an immunization because the client is not immunosuppressed. D) CORRECT: The client who has experienced adverse effects should inform the provider, who can weigh the risks of an immunizations.
A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply) A) Remove calluses using over-the-counter remedies. B) Apply lotion between toes. C) Test water temperature with the fingers before bathing. D) Trim toenails straight across. E) Wear closed-toe shoes.
Rationale: A) A podiatrist should remove calluses or corns. Over-the-counter remedies can increase the risk for tissue injury and an infection. B) Applying lotion between the toes increases moisture for growth of micro-organisms, which can lead to infection. C) The client should check bathwater with the wrist or a thermometer to ensure it is a safe temperature. The fingers might not be as sensitive. D) CORRECT: Trim toenails straight across to prevent injury to soft tissue of the toes. E) CORRECT: Wear closed-toe shoes to prevent injury of soft tissue of the toes and feet.
A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply) A) Urinalysis B) Erythrocyte sedimentation rate (ESR) C) BUN D) Antinuclear antibody (ANA) titer E) WBC count
Rationale: A) A urinalysis is not a laboratory test used to diagnose RA. This test can be used for detecting kidney failure. B) CORRECT: ESR is a laboratory test used to diagnose RA. This laboratory test will show an elevated result in clients who have RA. C) A BUN is not a laboratory test used to diagnose RA. This test can be used for detecting kidney failure. D) CORRECT: ANA titer is a laboratory test used to diagnose RA. This laboratory test will show a positive result in clients who have RA. E) CORRECT: WBC count is a laboratory test used to diagnose RA. This laboratory test will show a decreased result in clients who have RA.
A nurse is preparing to document administration of a meningococcal vaccine to a client. Which of the following information should the nurse include in the documentation? (Select all that apply) A) Age of client receiving the vaccine. B) Name of vaccine manufacturer. C) Vaccine expiration date. D) Date of administration. E) Serial number of the vaccine.
Rationale: A) Age of the person receiving an immunization is not included. B) CORRECT: Document the name of the vaccine manufacturer. C) CORRECT: Document the expiration date of the vaccine. D) CORRECT: Document the date the vaccine was administered. E) Document the lot number, not the serial number, of the vaccine.
A nurse is preparing to administer a varicella immunization to a client. Which of the following questions by the nurse is appropriate? A) "Are you allergic to eggs?" B) "Are you allergic to baker's yeast?" C) "Are you pregnant?" D) "Do you have a history of Guillain-Barre syndrome?"
Rationale: A) Allergy to eggs should be reviewed if the client is to receive an influenza immunization. B) Allergy to yeast should be reviewed if the client is to receive HPV immunization. C) CORRECT: Ask whether the client is pregnant because the varicella immunization is contraindicated during pregnancy. D) Guillain Barre syndrome is not a contraindication for varicella immunization.
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply) A) Anorexia B) Change in orientation C) Asterixis D) Ascites E) Fetor hepaticus
Rationale: A) Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. B) CORRECT: A change in orientation indicates hepatic encephalopathy in a client who has advanced cirrhosis. C) CORRECT: Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. D) Ascites can be present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. E) CORRECT: Fetor hepaticus (a fruity, musty breath odor) is a finding of hepatic encephalopathy in the client who has advanced cirrhosis.
A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A) Check blood glucose immediately after breakfast. B) Administer insulin when breakfast arrives. C) Hold breakfast for 1 hour after insulin administration. D) Clarify the prescription because insulin should not be administered at this time.
Rationale: A) Blood glucose should be checked prior to insulin administration to prevent an episode of hypoglycemia. B) CORRECT: Administer insulin aspart when breakfast arrives to avoid a hypoglycemic episode. Insulin aspart is rapid-acting and should be administered 5 to 10 minutes before breakfast. C) The client should eat within 5 to 15 minutes of taking insulin aspart to prevent hypoglycemia. D) Insulin aspart is administered at mealtimes.
A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply) A) Observe cardiac monitor for dysrhythmias. B) Observe for evidence of urinary tract infection. C) Initiate IV fluids using 0.9% sodium chloride. D) Administer a levothyroxine IV bolus. E) Provide warmth using a heating pad.
Rationale: A) CORRECT: A client who has myxedema can have a flat or inverted T wave as well as ST deviations. B) CORRECT: An infection (in the urinary tract) can precipitate myxedema coma. Observe the client for manifestations of infection so that the underlying illness can be treated. C) CORRECT: Hyponatremia is an expected finding in the presence of myxedema coma. IV therapy is administered using 0.9% sodium chloride. D) CORRECT: Myxedema coma is a severe complication of hypothyroidism that if left untreated can lead to coma or death. Levothyroxine is administered IV bolus to treat the condition. E) Provide warmth with extra clothing and blankets. Electric heating devices should be avoided because the combination of vasodilation, decreased sensation, and decreased alertness places the client at risk for burns.
A nurse is caring for a client who has syndrome of inappropriate anti-diuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply). A) Decreased blood sodium B) Urine specific gravity 1.001 C) Blood osmolarity 230 mOsm/L D) Polyuria E) Increased thirst
Rationale: A) CORRECT: An increase in the secretion of ADH leads to dilutional hyponatremia. B) A urine specific gravity greater than 1.030 (concentrated urine) is caused by an increase in the secretion of ADH. C) CORRECT: A decrease in blood osmolarity is caused by an increase in the secretion of ADH leading to water retention and dilution of blood components. D) Reduced urine output is caused by the increase in the secretion of ADH. E) Increased thirst is an expected finding in a client who has diabetes insipidus.
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply) A) Diuretic B) Beta-blocking agent C) Opioid analgesic D) Lactulose E) Sedative
Rationale: A) CORRECT: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. B) CORRECT: Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. C) Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis. D) CORRECT: Lactulose is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool. E) Sedatives are metabolized in the liver. They should not be administered to a client who has cirrhosis.
A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply) A) Recent influenza B) Decreased range of motion C) Hypersalivation D) Increased blood pressure E) Pain at rest
Rationale: A) CORRECT: Exacerbating factors, such as a recent illness like influenza, are indicative in clients who have RA. B) CORRECT: A decrease in range of motion is indicative in clients who have RA. C) Clients who have RA can experience xerostomia, not hypersalivation. D) Increased blood pressure is not indicative of RA. E) CORRECT: Pain at rest is indicative of RA.
A nurse in a provider's office is assessing a client who recently began taking levothyroxine to treat hypothyroidism. Which of the following findings should indicate to the nurse that the client might need a decrease in the dosage of the medication? A) Hand tremors B) Bradycardia C) Pallor D) Slow speech
Rationale: A) CORRECT: Identify hand tremors as a manifestation of hyperthyroidism that can result from thyroid hormone replacement therapy. Report this finding to the provider due to the possible need for a decrease in the dosage of medication. B) Bradycardia is an expected finding for hypothyroidism. This finding indicates the need for continued thyroid hormone replacement therapy with a possible increase in dosage. C) Pallor is an expected finding for hypothyroidism. This finding indicates the need for continued thyroid hormone replacement therapy with a possible increase in dosage. D) Slow thought processes and speech are expected findings for hypothyroidism. This finding indicates the need for continued thyroid hormone replacement therapy with a possible increase in dosage.
A nurse is teaching a patient who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A) "You can experience morning stiffness when you get out of bed." B) "You can experience abdominal pain." C) "You can experience weight gain." D) "You can experience low blood sugar."
Rationale: A) CORRECT: Include in the teaching that the client who has RA can experience stiffness in the joints upon rising. B) The client who has RA can experience pleuritic pain upon inspiration, not abdominal pain. C) The client who has RA can experience weight loss, not weight gain. D) The client who has RA does not experience a low blood sugar.
A nurse is reviewing the laboratory findings for a client who might have hyperthyroidism. The nurse should identify an elevation of which of the following substances as an indication that the client has this disorder? A) Triiodothyronine B) Plasma-free metanephrine C) Urine cortisol D) Urine osmolality
Rationale: A) CORRECT: Increased triiodothyronine (T3) indicates hyperthyroidism. B) An increase in plasma-free metanephrine indicates the presence of a pheochromocytoma (tumor of the cells of the adrenal medulla). C) A high cortisol level indicates hyperfunction of the adrenal cortex and can indicate that the client has Cushing's disease. D) Increased urine osmolality indicates SIADH.
A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A) Limit physical activity B) Avoid alcohol C) Take acetaminophen for comfort D) Wear a mask when in public places E) Eat small frequent meals
Rationale: A) CORRECT: Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process for a client who has hepatitis B. B) CORRECT: Alcohol is metabolized in the liver and should be avoided by the client who has hepatitis B. C) Acetaminophen is metabolized in the liver and should be avoided by the client who has hepatitis B. D) Hepatitis B is a blood-borne disease. Wearing a mask is not necessary to prevent transmission to others. E) CORRECT: The client who has hepatitis B should eat small, frequent meals to promote improved nutrition due to the presence of anorexia.
A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A) Monitor CBC B) Monitor triiodothyronine (T3) C) Instruct the client to increase consumption of shellfish. D) Advise the client to take the medication at the same time every day. E) Inform the client that an adverse effect of this medication is iodine toxicity.
Rationale: A) CORRECT: Methimazole can cause a number of hematologic effects, including leukopenia and thrombocytopenia. Monitor CBC. B) CORRECT: Methimazole reduces thyroid hormone production. Monitor T3. C) Methimazole reduces thyroid hormone production by blocking iodine. Instruct the client to limit iodine containing foods (shellfish) D) CORRECT: Methimazole should be taken at the same time every day to maintain blood levels. E) Iodine toxicity is an adverse effect of potassium iodide solution.
A nurse is caring for a client who has primary adrenal insufficiency and is preparing to undergo an ACTH stimulation test. Which of the following findings should the nurse expect after an IV injection of cosyntropin? A) No change in plasma cortisol B) Elevated fasting blood glucose C) Decrease in sodium D) Increase in urinary output
Rationale: A) CORRECT: No change in plasma cortisol indicates primary adrenal insufficiency (Addison's disease or hypocortisolism) after an IV injection of cosyntropin during the ACTH stimulation test due to an inadequate production of cortisol. B) An elevated fasting blood glucose helps identify diabetes mellitus. C) An increase in sodium indicates primary adrenal insufficiency (Addison's disease of hypocortisolism). D) A decrease in urinary output indicates primary adrenal insufficiency (Addison's disease or hypocortisolism).
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following is a risk factor for cholecystitis? A) Obesity B) Rapid weight gain C) Decreased blood triglyceride level D) Male sex
Rationale: A) CORRECT: Obesity is considered a risk factor for the development of cholecystitis. B) Rapid weight loss is a risk factor for the development of cholecystitis. C) Increased blood cholesterol levels are a risk factor for developing cholecystitis. D) Female sex is a risk factor for the development of cholecystitis.
A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea. Their temperature is 38.1°C (100.6°F) orally. The client is concerned about the possibility of having HIV. Which of the following actions should the nurse take? (Select all that apply) A) Perform a physical assessment. B) Determine when manifestations began. C) Teach the client about HIV transmission. D) Draw blood for HIV testing. E) Obtain a sexual history.
Rationale: A) CORRECT: Perform a physical assessment to gather data about the client's condition. B) CORRECT: Gather more data to determine whether the manifestations are acute or chronic. C) Teaching the client about HIV transmission is not an appropriate action at this time. D) Drawing blood for HIV testing is not an appropriate action at this time. E) CORRECT: Obtain a sexual history to determine how the virus was transmitted.
A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply) A) Perinatal exposure B) Pregnancy C) Monogamous sex partner D) Older adult woman E) Occupationalexposure
Rationale: A) CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take precautionary measures to prevent HIV exposure. B) Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C) Having a monogamous sex partner is not a risk factor associated with the HIV virus. D) CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due to vaginal dryness and the thinning of the vaginal wall. E) CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.
A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply) A) Western blot B) Indirect immunofluorescence assay C) CD4+ T-lymphocyte count D) HIV RNA quantification test E) Cerebrospinal fluid (CSF) analysis
Rationale: A) CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B) CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. C) CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. D) HIV RNA quantification tests are used to determine vial level and to monitor treatment. E) A CSF analysis can be used to confirm meningitis.
A nurse is reviewing the health record of a client who has syndrome of inappropriate anti- diuretic hormone (SIADH). Which of the following laboratory findings should the nurse expect? (Select all that apply) A) Low sodium B) High potassium C) Increased urine osmolality D) High urine sodium E) Increased urine specific gravity
Rationale: A) CORRECT: SIADH results in water retention, causing a low sodium level. B) SIADH does not affect potassium levels. C) CORRECT: SIADH results in an increase in urine osmolality due to the decreased urine volume. D) CORRECT: SIADH results in water retention, causing a high urine sodium level. E) CORRECT: SIADH results in water retention, causing an increase in urine specific gravity.
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) A) "I plan to eat small, frequent meals." B) "I will eat easy-to-digest foods with limited spice." C) "I will use skim milk when cooking." D) "I plan to drink regular cola." E) "I will limit alcohol intake to two drinks per day."
Rationale: A) CORRECT: Small, frequent meals are recommended for the client who has pancreatitis. B) CORRECT: Bland, easy-to-digest foods are recommended for the client who has pancreatitis. C) CORRECT: Low-fat foods are recommended for the client who has pancreatitis. D) Caffeine-free beverages are recommended for the client who has pancreatitis. Regular cola contains caffeine. E) The client who has pancreatitis should avoid any alcohol intake.
A nurse is planning care for a client who has Cushing's disease. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following? (Select all that apply) A) Infection B) Gastric ulcer C) Renal calculi D) Bone fractures E) Dysphagia
Rationale: A) CORRECT: Suppression of the immune system places the client at risk for infection. B) CORRECT: The overproduction of cortisol inhibits the production of a protective mucus lining in the stomach and causes an increase in the amount of gastric acid. These factors place clients who have Cushing's disease at increased risk for gastric ulcers. C) Clients who have Cushing's disease are not at risk for renal calculi, but they are at risk for neurologic and cardiovascular problems. D) CORRECT: Clients who have Cushing's disease are at risk for bone fractures because decreased calcium absorption leads to osteoporosis. E) Clients who have Cushing's disease are not at risk for dysphagia, but they are at risk for other gastrointestinal problems, including anorexia, nausea, vomiting, and abdominal pain.
A nurse is preparing to receive a client from the PACU who is post-operative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply) A) Suction equipment B) Humidified oxygen C) Flashlight D) Tracheostomy tray E) Chesttubetray
Rationale: A) CORRECT: The client can require oral or tracheal suctioning. Ensure that suctioning equipment is available. B) CORRECT: The client can require supplemental oxygen due to respiratory complications. Humidified oxygen thins secretions and promotes respiratory exchange. This equipment should be available. C) A flashlight is used to measure the reaction of the pupils to light for a client who has an intracranial disorder. Checking pupil reaction with a flashlight is not indicated for this client. D) CORRECT: The client can experience respiratory obstruction. A tracheostomy tray should be available at the bedside. E) A chest tube tray should be used for a client who develops a hemothorax or pneumothorax. This is not an expected complication of a thyroidectomy. This equipment is not indicated for this client.
A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply) A) Eat at regular intervals. B) Decrease intake of saturated fats. C) Increase daily fiber intake. D) Limit saturated fat intake to 15% of daily caloric intake. E) Include omega-3 fatty acids in the diet.
Rationale: A) CORRECT: The client should eat at regular intervals throughout the day to maintain blood glucose levels. B) CORRECT: Healthy nutrition should include lowering LDL by decreasing intake of saturated fats, which can prevent diabetes and hyperlipidemia. C) CORRECT: Healthy nutrition should include increasing dietary fiber to control weight gain and decrease the risk of diabetes and hyperlipidemia. D) The recommended saturated fat intake is no more than 7% of total daily caloric intake. E) CORRECT: Healthy nutrition should include omega-3 fatty acids for secondary prevention of diabetes and heart disease.
At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A) Weight gain B) Fatigue C) Fragile skin D) Joint pain
Rationale: A) CORRECT: The greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure; therefore, this is the priority finding. B) Fatigue will reduce the client's ability to perform self-care; however, another finding is the priority. C) Fragile skin increases the client's risk for tears or lesions; however, another finding is the priority. D) Joint pain can reduce the client's mobility; however, another finding is the priority.
A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for the client? (Select all that apply) A) Sodium 150 mEq/L B) Potassium 3.3 mEq/L C) Calcium 8.0 mg/dL D) Lymphocyte count 35% E) Fasting glucose 145 mg/dL
Rationale: A) CORRECT: This finding is above the expected reference range. Hypernatremia is an expected finding for clients who have Cushing's disease. B) CORRECT: This finding is below the expected reference range. Hypokalemia is an expected finding for clients who have Cushing's disease. C) CORRECT: This finding is below the expected reference range. Hypocalcemia is an expected finding for clients who have Cushing's disease. D) This finding is within the expected reference range. A decreased lymphocyte count is an expected finding for clients who have Cushing's disease. E) CORRECT: This finding is above the expected reference range. Clients who have Cushing's disease have an elevated fasting blood glucose because the disorder affects glucose metabolism.
A nurse is caring for a client who asks why the provider bases the medication regimen on HbA1c results instead of the log of morning fasting blood glucose results. Which of the following responses should the nurse make? A) "HbA1c measures how well insulin is regulating your blood glucose between meals." B) "HbA1c indicates how well you have regulated your blood glucose over the past 120 days." C) "HbA1c is the first test your doctor prescribed to determine that you have diabetes." D) "HbA1c determines if your doctor should adjust your insulin dosage."
Rationale: A) Capillary glucose monitoring evaluates how well insulin is regulating blood glucose between meals. B) CORRECT: HbA1c measures blood glucose control over the past 120 days. C) A fasting blood glucose is the first test providers prescribe to diagnose diabetes mellitus. HbA1c is not a screening test. D) Capillary glucose monitoring evaluates how well insulin regulates blood glucose.
A nurse is caring for a client who is 6 hours post-operative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? A) RBCs B) Ketones C) Glucose D) Streptococci
Rationale: A) Cerebrospinal fluid does not contain RBCs unless the client has a cerebral hemorrhage or the procedure was traumatic. The nurse is not required to test for this. B) Cerebrospinal fluid does not contain ketones, although it does contain protein and lactic acid. C) CORRECT: Cerebral spinal fluid contains glucose. Test nasal drainage for glucose. D) Cerebrospinal fluid does not contain any bacteria unless the client has meningitis or another infection that involves the brain and spinal cord. The nurse is not required to test for this.
A nurse is collecting an admission history from a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply) A) Diarrhea B) Menorrhagia C) Dry skin D) Increased libido E) Hoarseness
Rationale: A) Constipation is a manifestation of hypothyroidism. B) CORRECT: Abnormal menstrual periods, including menorrhagia and amenorrhea, are manifestations of hypothyroidism. C) CORRECT: Dry skin is a manifestation of hypothyroidism. D) Decreased libido is a manifestation of hypothyroidism. E) CORRECT: Hoarseness is a manifestation of hypothyroidism.
A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected? A) Elevated T4 B) Decreased T3 C) Elevated thyroid stimulating hormone D) Decreased cholesterol
Rationale: A) Decreased T4 is an expected finding for a client who has hypothyroidism. B) CORRECT: Decreased levels of T3 in the blood is an expected finding for a client who has hypothyroidism. C) Decreased thyroid stimulating hormone level is an expected finding in a client who has secondary hypothyroidism. D) Elevated cholesterol is an expected finding for a client who has hypothyroidism.
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an unexpected finding? A) Blood amylase 80 units/L B) WBC 9,000/mm3 C) Direct bilirubin 2.1 mg/dL D) Alkaline phosphatase 25 units/L
Rationale: A) Expect the client who has cholelithiasis to have an elevated blood amylase level if pancreatic involvement is present. A blood amylase of 80 units/L is within the expected reference range. B) Expect the client who has cholelithiasis to have an elevated WBC level due to inflammation. A WBC of 9,000/mm3 is within the expected reference range. C) CORRECT: Expect the client who has cholelithiasis to have an elevated bilirubin level if the bile duct is obstructed. A direct bilirubin level of 2.1 mg/dL is above the expected reference range. D) Expect the client who has cholelithiasis to have an elevated alkaline phosphatase (ALP) level if the common bile duct is obstructed. An ALP of 25 units/L is less than the expected reference range.
A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? A) Generalized cyanosis B) Hyperactive bowel sounds C) Gray-blue discoloration of the skin around the umbilicus D) Wheezing in the lower lung fields
Rationale: A) Expect to find generalized jaundice. B) Expect to find absent or decreased bowel sounds. C) CORRECT: A gray-blue discoloration in the periumbilical area is a manifestation of pancreatitis. D) Expect to find diminished breath sounds as well as dyspnea or orthopnea.
A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse expect? A) Presence of glucose B) Decreased specific gravity C) Presence of ketones D) Presence of red blood cells
Rationale: A) Glucose in the urine is indicative of diabetes mellitus. B) CORRECT: The urine of a client who has diabetes insipidus will be dilute with a urine specific gravity of less than 1.005. C) Ketones in the urine is indicative of diabetes mellitus. D) Red blood cells in the urine is indicative of diabetes mellitus.
A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A) Initiate contact precautions. B) Weight the client weekly. C) Measure abdominal girth at the base of the ribcage. D) Provide a high-calorie, high-carbohydrate diet.
Rationale: A) Hepatitis B is transmitted via blood. Standard precautions are adequate. B) Daily weights are obtained to monitor fluid status. C) The client's abdominal girth is measured over the largest part of the abdomen, which will vary by client. D) CORRECT: The client who has hepatitis B should have a diet high in calories and carbohydrates.
A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves' disease. The nurse should identify that which of the following laboratory results is an expected finding? A) Decreased thyrotropin receptor antibodies B) Decreased thyroid-stimulating hormone (TSH) C) Decreased free thyroxine index D) Decreased triiodothyronine
Rationale: A) In the presence of Graves' disease, elevated thyrotropin receptor antibodies is an expected finding. B) CORRECT: In the presence of Graves' disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. C) In the presence of Graves' disease, elevated free thyroxine index is an expected finding. D) In the presence of Graves' disease, elevated triiodothyronine is an expected finding.
A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply) A) Weight gain is expected while taking this medication. B) Medication should not be discontinued without the advice of the provider. C) Follow-up blood TSH levels should be obtained. D) Take the medication on an empty stomach. E) Use fiber laxatives for constipation.
Rationale: A) Levothyroxine speeds up metabolism. Weight loss is an expected effect. B) CORRECT: The provider carefully titrates the dosage of this medication. It should be increased slowly until the client reaches a euthyroid state. The client should not discontinue the medication unless directed to do so by the provider. C) CORRECT: Blood TSH levels are used to monitor the effectiveness of the medication. D) CORRECT: The medication should be taken on an empty stomach to promote absorption. E) Fiber laxatives reduce absorption of the medication and should be avoided.
A nurse is reviewing strategies to promote comfort with a client who received an immunization. Which of the following information should the nurse include? (Select all that apply) A) Massage the injection site. B) Apply a cool compress to the injection site. C) Take acetaminophen or ibuprofen. D) Use the affected extremity. E) Apply an antimicrobial ointment to the injection site.
Rationale: A) Massaging the injection site for any extended period of time can increase localized discomfort. B) CORRECT: Applying a cool compress to the injection site can relieve discomfort from the localized reaction. C) CORRECT: Taking an antipyretic can relieve a low-grade fever and localized discomfort at the injection site. D) CORRECT: Mobilizing the affected extremity will help relieve discomfort due to a localized reaction. E) Applying an antimicrobial ointment at the injection site is not indicated.
A nurse is caring for a client who has a WBC count of 20,000/mm3. The nurse should conclude that the client has which of the following? A) Neutropenia B) Leukocytosis C) Left shift D) Leukopenia
Rationale: A) Neutropenia is a neutrophil count less than 2,000/mm3. B) CORRECT: Leukocytosis is a WBC count greater than 10,000/mm3, which can indicate inflammation or infection. C) A left shift is an increase in immature neutrophils (bands or stabs) that occurs with acute infection. D) Leukopenia is a total WBC count of less than 4,000/mm3, which can indicate overwhelming infection or drug toxicity.
A nurse is reviewing the laboratory findings of a client who has measles. The nurse should expect to find an increase in which of the following types of WBCs? A) Neutrophils B) Basophils C) Lymphocytes D) Eosinophils
Rationale: A) Neutrophils increase with an acute bacterial infection. Measles is a viral infection. B) Basophils increase with leukemia. C) CORRECT: Lymphocytes increase with viral infections (measles, mumps, mononucleosis). D) Eosinophils increase with allergic reactions, leukemia, eczema, and parasitic infections.
A nurse is reviewing a new prescription for chenodiol with a client who has cholelithiasis. Which of the following information should the nurse include in the teaching? A) This medication is used to decrease acute biliary pain. B) This medication requires thyroid function monitoring every 6 months. C) This medication is not recommended for clients who have diabetes mellitus. D) This medication dissolves gallstones gradually over a period of up to 2 years.
Rationale: A) Opioid analgesics are preferred for the treatment of acute biliary pain. B) The client should have an ultrasound of the gallbladder every 6 months during the first year of treatment to determine effectiveness of the medication. C) Chenodiol is used cautiously in clients who have hepatic conditions or disorders with varices. D) CORRECT: Chenodiol is a bile acide that gradually dissolves cholesterol-based gall stones. The medication can be take for up to 2 years.
A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? A) Instruct the client to chew the medication before swallowing. B) Offer a glass of water following medication administration. C) Administer the medication 30 minutes before meals. D) Sprinkle the contents on peanut butter.
Rationale: A) Pancrelipase should be swallowed without chewing to reduce irritation and slow the release of the medication. B) CORRECT: Drink a full glass of water following administration of pancrelipase. C) Pancrelipase should be administered with every meal and snack. D) The contents of the pancrelipase capsule can be sprinkled on non-protein foods, and peanut butter is a protein food.
A nurse is caring for a client who has a blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A) Recheck blood glucose in 15 minutes. B) Provide a carbohydrate and protein food. C) Provide 15g of simple carbohydrates. D) Report findings to the provider.
Rationale: A) Recheck the blood glucose in 15 minutes after a rapidly absorbed carbohydrate is ingested; however, another action is the priority. B) Give the client a carbohydrate and protein food if the next meal is more than 1 hour away after the blood glucose returns to a normal range; however, take another action first. C) CORRECT: The greatest risk to the client is injury from hypoglycemia; therefore, the priority action to take is to administer 15 to 20g of a rapidly absorbed carbohydrate (grape juice). D) Report the findings to the provider; however, take another action first.
A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A) "The scope will be passed through your rectum." B) "You might have shoulder pain after surgery." C) "You will have a Jackson-Pratt drain in place after surgery." D) "You should limit how often you walk for 1 to 2 weeks."
Rationale: A) Surgery is possibly performed through the rectum during the natural orifice transluminal endoscopic surgery (NOTES) approach. B) CORRECT: Shoulder pain is expected postoperatively due to free air that is introduced into the abdomen during laparoscopic surgery. C) A Jackson-Pratt can be placed during the open surgery approach. D) The client is instructed to ambulate frequently following a laparoscopic surgical approach to minimize the free air that has been introduced.
A nurse is assessing a client during a water deprivation test. For which of the following complications should the nurse monitor the client? A) Bradycardia B) Orthostatic hypotension C) Neck vein distention D) Crackles in the lungs
Rationale: A) Tachycardia is a complication to monitor for during a water deprivation test due to dehydration. B) CORRECT: Monitor for orthostatic hypotension resulting from dehydration during a water deprivation test. C) Flat neck veins are likely during a water deprivation test due to dehydration. D) Monitor the client for dizziness rather than lung crackles during a water deprivation test.
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A) Take baths rather than showers. B) Resume a diet of choice. C) Cleanse the puncture site using mild soap and water. D) Remove adhesive strips from the puncture site in 24 hours. E) Report nausea and vomiting to the surgeon.
Rationale: A) The client can take a bath or shower within 1 to 2 days following the surgery. B) CORRECT: The client is able to resume a regular diet of choice upon discharge. C) CORRECT: The client should cleanse the puncture site with mild soap and water to decrease the risk of infection. D) The adhesive strips covering the puncture site should remain in place until they fall off naturally. E) CORRECT: The client should report nausea, vomiting, or abdominal pain to the surgeon.
A nurse is providing discharge teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply) A) Brush teeth after every meal or snack. B) Avoid bending at the knees. C) Eat a high-fiber diet. D) Notify the provider of increased swallowing. E) Notify the provider of a diminished sense of smell.
Rationale: A) The client should avoid brushing their teeth for 2 weeks to allow time for the incision to heal. B) The client should avoid bending at the waist. If bending is necessary, they should bend at the knees. C) CORRECT: To avoid constipation, which contributes to increased intracranial pressure, the client should eat a high-fiber diet and take docusate. D) CORRECT: Increased swallowing is an indication of leakage of cerebrospinal fluid. The client should notify their provider. E) Diminished sense of smell is an expected finding after surgery.
A nurse is planning care for a client who has acromegaly and is post-operative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan? A) Maintain the client in a low-Fowler's position. B) Encourage deep breathing and coughing. C) Encourage the client to brush their teeth when awake and alert. D) Observe dressing drainage for the presence of glucose.
Rationale: A) The client should be placed into a high-Fowler's position. B) Coughing should be limited in the client who is post-operative, as this increases intracranial pressure and can cause a leak of CSF. C) Oral care for the client who is post-operative following a transsphenoidal hypophysectomy includes oral rinses and flossing. Brushing teeth can cause a leak of CSF and is contraindicated. D) CORRECT: The nurse should monitor the drainage to the mustache dressing and observe for the presence of glucose, which could indicate the presence of CSF. Notify the provider if this occurs.
A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A) "I will choose a diet high in fat to help gain weight." B) "I will be sure to eat three large meals daily." C) "I will drink up to 1 liter of liquid each day." D) "I will add high-protein foods to my diet."
Rationale: A) The client should be taught to avoid high-fat foods to gain weight because fat intolerance—causing flatus, bloating, and diarrhea—is common in clients who have HIV/AIDS. B) The client should be taught that small frequent meals (such as six meals daily) are better tolerated than three large meals. C) The client should be taught to drink 2 to 3 L of liquids daily to maintain nutrition status. D) CORRECT: The client should be taught to add high-protein, high-calorie foods to the diet daily as the best way to gain weight and maintain health.
A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply) A) Anorexia B) Heat tolerance C) Constipation D) Palpitations E) Weightloss F) Bradycardia
Rationale: A) The client who has hyperthyroidism has an increased metabolic rate, resulting in increased hunger. B) CORRECT: Hyperthyroidism increases the client's metabolism, causing heat tolerance. C) Diarrhea is an expected finding for the client who has hyperthyroidism. D) CORRECT: Hyperthyroidism increases the client's metabolism, causing palpitations. E) CORRECT: Hyperthyroidism increases the client's metabolism, causing weight loss. F) Hyperthyroidism increases the client's metabolism, causing tachycardia.
A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A) Decreased blood lipase level B) Decreased blood amylase level C) Increased blood calcium level D) Increased blood glucose level
Rationale: A) The client will experience an elevated blood lipase level due to pancreatic cell injury. B) The client will experience an elevated blood amylase level due to pancreatic cell injury. C) The client will experience a decreased blood calcium level due to fat necrosis. D) CORRECT: The client will experience an increased blood glucose level due to pancreatic cell injury, which results in impaired metabolism of carbohydrates due to a decrease in the release of insulin.
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? A) Presence of immunoglobulin G antibodies (IgG) B) Positive EIA test C) Aspartate aminotransferase (AST) 35 units/L D) Alanine aminotransferase (ALT) 15 IU/L
Rationale: A) The presence of IgG is an expected laboratory finding in a client who has hepatitis A infection. B) CORRECT: A positive EIA test is an expected laboratory finding in a client who has a new diagnosis of hepatitis C. C) AST is elevated in clients who have hepatitis C infection; 35 units/L is within the expected reference range. D) ALT is elevated in clients who have hepatitis C infection; 15 units/L is within the expected reference range.
A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose of 278 mg/dL. Which of the following actions should the nurse take? A) Draw up the regular insulin and then the glargine insulin in the same syringe. B) Draw up the glargine insulin then the regular insulin in the same syringe. C) Draw up and administer regular and glargine insulin in separate syringes. D) Administer the regular insulin, wait 1 hour, and then administer the glargine insulin.
Rationale: A) These insulins are not compatible and should not be drawn up in the same syringe. B) These insulins are not compatible and should not be drawn up in the same syringe. C) CORRECT: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe. D) There is no need for the nurse to separate the timing of administration for the two insulins.
A nurse is preparing to administer an IM injection of immune globulin to a client who has been exposed to hepatitis A. Which of the following statements by the nurse is appropriate? A) "This medication offers permanent immunity to hepatitis A." B) "This medication involves three injections over several months." C) "This medication provides you with an immune response more quickly than your body can produce it." D) "This medication contains an attenuated virus to help your body create antibodies."
Rationale: A) This medication produces passive-artificial immunity that lasts only several weeks or months. B) This medication produces passive-artificial immunity and is given one time after exposure to hepatitis A. C) CORRECT: This medication produces passive-artificial immunity and contains antibodies to help protect against hepatitis A for several weeks or months. D) This medication contains antibodies, not an attenuated virus.
A nurse is preparing to administer a scratch test to a client who has possible food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (Select all that apply) A) Cleanse the client's skin with povidone-iodine. B) Ask the client about previous reactions to allergens. C) Ask the client about medications taken over the past several days. D) Inform the client to expect itching at one site. E) Obtain emergency resuscitation equipment.
Rationale: A) Use soap and water to cleanse the skin. Povidone-iodine could interfere with an allergen and elicit a response. B) CORRECT: Ask the client about any previous reactions to allergens, which could indicate an increased risk of an anaphylactic reaction. C) CORRECT: Ask the client about medications taken over the past several days. Antihistamines and corticosteroids can suppress reactions. D) CORRECT: Histamine will be applied at a control site, so the client will probably have itching at this site. E) CORRECT: Emergency equipment should be available, even if the client denies previous anaphylactic reactions.
A nurse is assessing a client who is 12 hours post-operative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? (Select all that apply) A) Bradycardia B) Hypothermia C) Dyspnea D) Abdominal pain E) Mental confusion
Rationale: A) When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in tachycardia. B) When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in a high fever. C) CORRECT: Excessive levels of thyroid hormone can cause the client to experience dyspnea. D) CORRECT: When thyroid crisis occurs, the client can experience gastrointestinal conditions (vomiting, diarrhea, and abdominal pain). E) CORRECT: Excessive thyroid hormone levels can cause the client to experience mental confusion.
A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol. Which of the following information should the nurse include? A) "An adverse effect of this medication is jaundice." B) "Take your pulse before each dose." C) "The purpose of this medication is to decrease production of thyroid hormone." D) "You should stop taking this medication if you have a sore throat."
Rationale: A) Yellowing of the skin is an adverse effect of methimazole. B) CORRECT: Propranolol can cause bradycardia. The client should take their pulse before each dose. If there is a significant change, they should withhold the dose and consult the provider. C) The purpose of propranolol is to suppress tachycardia, diaphoresis, and other effects of Graves' disease. D) Sore throat is not an adverse effect of this medication. The client should not discontinue taking this medication because this action can result in tachycardia and dysrhythmias.
