RNSG 1128 Quiz (unfinished)

Which skin condition would the RN expect when performing a physical assessment on a client with a hx of hypothyroidism? O Dry. O Moist. O Flushed. O Smooth.

Dry. Caused by decreased function of sebaceous glands; decreased T3 & T4, which control basal metabolic rate, & alter function of almost every body system. The skin will appear pale, not flushed. Moist, smooth skin occurs c̅ increased T3 & T4, & n basal metabolic rate.

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, which action is MOST therapeutic? O Encouraging her peers to visit. O Keeping her lower body covered. O Placing her in a room by herself. O Limiting her visitors to the family.

Encouraging her peers to visit. Peer acceptance is crucial during this period; friends need the chance to accept the pt c̅ 1 leg. #2 doesn't help the pt or others accept the loss. #3 will increase feelings of alienation. #4 won't allow pt to be accepted by peers, only family.

The RN is caring for a client who reports sweating, tachycardia, & tremors. The lab report of pt shows serum cortisol < normal & blood glucose = 60 mg/dL. Which med would be administered? O Glucagon. O Kayexalate. O Hydrocortisone. O Insulin c̅ dextrose in normal saline.

Glucagon. Decreased cortisol impairs glucose metabolism. Blood glucose = 60 mg/dL - hypoglycemia. Glucagon is admin to manage blood glucose. #2: manages K+-binding resin that facilitates K+ excretion & manages hyperkalemia. #3 IM: q12h - hormone replacement in adrenal insuff. #4: manage hyperkalemia - causes an intracellular shift of K+.

Which serum laboratory value in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrythmias? O Calcium = 9.5 mg/dL (2.375 mmol/L) O Potassium = 7.02 mg/dL ( <- mmol/L) O Bicarbonate = 22.8 mg/dL ( <- mmol/L) O Phosphorus = 4.1 mg/dL

Potassium = 7.02 mg/dL ( <- mmol/L). K=3.5 - 5 mEq/L (3.5-5 mmol/L). K > 6 mEq/L -> muscle weakness & cardiac arrythm. P=2.4-4.4 mEq/L (0.78-1.42 mmol/L) Ca=8.6-10.2 mg/dL (2.15-2.55 mmol/L) HCO3=22-26 mEq/L or mmol/L.

For which condition is an adult client with a weakened urinary sphincter at risk? O Bladder distention. O Skin irritation. O Tendency to fall. O Urinary retention.

Skin irritation. Weakened urinary sphincter -> dribbling -> skin irritation. Hygiene in peri-area reduces chance of infection/rash. RN should assess for S/S of bladder distension in pts c̅ urinary retention. Keeping bedside light on at noc prevents falls in pts c̅ nocturia.

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission, the client asks the RN, "Do you think I have anything serious, like cancer?" Which response by the RN is MOST appropriate? O "What makes you think you have cancer?" O "I don't know if you do; let's talk about it." O "Why don't you discuss this with your PCP?" O " You needn't worry now; we won't know the answer for a few days."

"I don't know if you do; let's talk about it." The RN recognizes the pt's concern & listens. Since the pt didn't say the dx is cancer, #1 may cause pt to be defensive. #3 & #4 avoids the question, pt thinks RN doesn't want to listen, cuts off pt communication & feelings.

A client experiencing thyrotoxic crisis tells the nurse, "I know I'm going to die. I'm very sick." Which is the BEST response by the nurse? O "You must feel very sick and frightened." O "Tell me why you feel you are going to die." O "I can understand how you feel, but people do not die from this problem." O "If you would like, I will call your family and tell them to come to the hospital."

"You must feel very sick and frightened." #1- Reflects the pt's feelings & encourages further exploration of concerns. #2- Doesn't reflect the feeling/tone of the pt's statement; also the pt may not be able to answer a "why" question. #3- Is false reassurance; thyrotoxic crisis is capable of causing death. #4- May reinforce the pt's anxiety & avoids discussing the pt's concerns; it cuts off communication.

Which clinical findings are commonly associated with hyperglycemia? Select all that apply. O Polyuria. O Polydipsia. O Polyphagia. O Polydysplasia.

- Polyuria. - Polydipsia. - Polyphagia. S/S of hyperglycemia.

The nurse is assessing four clients for risk factors for developing a pressure injury. List in order of priority the client with the greatest risk for developing a pressure injury to the client with the smallest risk. ___ 70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound. ___ 78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory. ___ 62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift. ___ 25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory.

1, 4, 2, 3. Risk factors for pressure injures: inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed -> this makes the 70 y.o. man the greatest for developing a PI. An inability to sense/move the left side will inhibit changing positions s̅ assistance -> this makes the 62 y.o. woman diagnosed c̅ CVA #2. Urine/fecal incontinence causes impaired TI in perineal & sacral areas -> this makes the 25 y.o. who is unable to verbalize needs #3. Continent & ambulatory, adequate nutrition, elective surgery indicates adequate general health -> this makes the 78 y.o. who has minimal risks #4.

A client with full-thickness burns of the entire right arm states, "I'll never be able to use my arm again. I'll be scarred forever." Which is the BEST initial response by the nurse? O "Think about how lucky you are. You're still alive." O "Minimizing scarring is the goal of the entire professional staff." O "Being worried is understandable, but it's really too early to tell." O "Try not to worry. Concentrate on doing your range-of-motion exercises."

"Minimizing scarring is the goal of the entire professional staff." #2 - Telling the pt that a positive outcome is the goal of the staff is a truthful answer that offers some hope s̅ false reassurance. #1 - The adolescent isn't concerned about having escaped death; telling the pt to be glad to be alive will cut off communication. #3 - Telling the adolescent that it's too early to anticipate scarring is misinformation. #4 - Ignoring the adolescent's concerns is not therapeutic & cuts off communication.

Which finding would the nurse identify as normal inflammation versus an infection when assessing a client's wound that was sutured 72 hours ago? O Client report of increasing pain. O A temperature of 101.6°F (38.6°C). O Small amounts of purulent drainage. O A slight red border around the wound.

A slight red border around the wound. A slight red border during the first few days is due to normal inflammation. Increased pain, a temperature above 101°F (38.3°C), & purulent drainage are all indications of potential infection.

Which clinical manifestation indicates a need for the RN to contact the HCP to increase the IV infusion for an older client with an infection? O Pruritus. O Erythema. O Acute confusion. O General Malaise.

Acute confusion. Acute confusion is an early sign of dehydration in an older adult client. Additional fluids are N/A if pruritus, erythema, or general malaise develop in this pt.

Which would the nurse identify as a risk factor for hyponatremia? O Inadequate fluid intake. O Drainage from a T-tube. O Total parenteral nutrition. O Hypertonic tube feedings.

Drainage from a T-tube. 2# - Bile is rich in Na; therefore, continuous bile loss caused by drainage, fistulas, & vomiting can cause hyponatremia. 1# - Inadequate fluid intake results in hypernatremia, not hyponatremia. 3# - Total parenteral nutrition results in hypernatremia, not hyponatremia. 4# - Hypertonic tube feedings result in hypernatremia, not hyponatremia.

Which combination of client responses would the RN determine represents the HIGHEST risk for the development of PI? O Incontinence; inability to move independently. O Periodic diaphoresis; occasional sliding down in bed. O Minimal reaction to painful stimuli; receiving tube feedings. O Spending extensive time in a chair; BMI of 23.

Incontinence; inability to move independently. #1 is highest risk due to constant exposure to urine, constant pressure compressing cap- illary beds. #2: still risk factor, but not highest. #3: 1 part (stim) is a risk factor, the other part (tube) promotes TI. #4: 1 part (chair) is a risk factor, the other part (BMI) is WNL and can be moved to relieve pressure easily.

A client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. Which action would the nurse plan to take? O Perform a neurovascular assessment of the extremity. O Reassure the client that these injuries are not that serious. O Gather equipment needed for the application of skeletal traction. O Prepare the client for a surgical reduction of the injured extremity.

Perform a neurovascular assessment of the extremity. #1 - Identifying the status of the damage is the priority. Before a tx protocol is determined, the presence of nerve/vascular damage & compartment syndrome must be identified. #2 - False reassurance is never appropriate. #3 - Skeletal traction is used rarely. #4 - Closed fxs in the absence of soft tissue damage are reduced by manipulation. Closed fxs c̅ soft tissue damage may require an external fixation device to reduce the fx, immobilize the bone, & allow for tx of the soft tissue damage. Preparing the pt for surgery is premature; more data are necessary before a tx option is determined.

Which is a secondary cause of adrenal insufficiency? O Hemorrhage. O Tuberculosis. O Pituitary tumors. O Metastatic cancer.

Pituitary tumors. AKA Addison disease. #1, #2, & #4 are primary causes.

Which finding supports the diagnosis of a hyperfunctioning adrenal gland? O Serum Sodium = 130 mEq/L (mmol/L). O Serum Bicarbonate = 24 mEq/L (mmol/L). O Blood Urea Nitrogen = 12 mg/dL (4.29 mmol/L). O Serum Potassium = 2.8 mEq/L (mmol/L).

Serum Potassium = 2.8 mEq/L (mmol/L). A hyperfun. adrenal gland manifests as dec. K+ levels. Na=135-145 mEq/L (mmol/L). HCO3=22-26 mEq/L (mmol/L). BUN=7-20 mg/dL (2.5-7.14 mmol/L). P=3.5-5 mEq/L (mmol/L).

When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? O Complete blood cell count. O Serum potassium level. O X-ray film of long bones. O Blood cultures X3.

Serum potassium levels. A serum K+ level < 3.5 mEq/L = hypokalemia. CBC, X-ray of long bones, & blood cultures X3 have no significance in the dx of a K+ deficit.

Which person is at greatest risk for a mental health crisis? O The individual who has no family and very few friends. O The individual who has had many losses over a lifetime. O The individual who has a high-stress job with many responsibilities. O The individual who has limited coping skills and stress is ongoing.

The individual who has limited coping skills and stress is ongoing. A crisis occurs when stress (real or imagined) cannot be controlled by the person's usual coping mechanisms. Isolation does not necessarily cause a crisis; people do cope c̅ being alone, but if a crisis occurs, support systems are helpful. A person who experiences loss over a lifetime may have developed a variety of coping mechanisms & is less likely to experience a crisis. People c̅ high-stress jobs can learn to develop coping mechanisms, & many people enjoy the stimulation & responsibility that accompanies such a job.

Which nursing action is the PRIORITY when the RN discovers in an admission assessment that a client has a stage 1 pressure ulcer? O Turn & reposition pt q2h. O Cover ulcer c̅ an occlusive, transparent Dsg. O Clean ulcer c̅ hydrogen peroxide & leave open to air. O Prove client c̅ diet high in vitamin C, Zinc, & protein.

Turn & reposition client q2h. This prevents further breakdown. Other measures are to relieve pressure on affected area, prevent progression, promote healing. #2 & #3 are not recommended. #4 will aid in healing and prevent progression, but not priority.