S3U1

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement.

2. Maintain a patent airway. (Saunders)

The night shift nurse nots at the end of her shift that a client who had a mastectomy has a total of 90 mL of serosanguineous drainage from the incision over a 24 hour period. What is the best nursing action? 1. Report amount of drainage to the physician. 2. Start frequent blood pressure checks and observe for hemorrhage. 3. Continue to monitor the drainage. 4. Reinforce packing at the wound site.

3. Continue to monitor the drainage. (Zerwekh)

Insulin lowering blood glucose when levels are high; glucagon raising blood glucose when levels are low is example of: A. Negative feedback B. Positive feedback C. Biological rhythms D. Central nervous system

A. Negative feedback (power point)

6. The nurse preparing to care for a patient after a suspected stroke would question an order for a(n) a. antihypertensive. b. antipyretic. c. osmotic diuretic. d. sedative.

a. antihypertensive. (Giddens)

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? SATA. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

1, 3 (Saunders)

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? SATA. 1. Loosening restrictive clothing. 2. Restraining the client's limbs. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward. 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

1, 3, 4 (Saunders)

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? SATA. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1,2,4,5 (Saunders)

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in the planning for the client's safety? SATA. 1. Padding the side rails of the bed. 2. Placing an airway at the bedside. 3. Placing the bed in the high position. 4. Putting a padded tongue blade at the head of the bed. 5. Placing oxygen and suction equipment at the bedside. 6. Flushing the intravenous catheter to ensure that the site is patent.

1,2,5,6 (Saunders)

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicated the need for additional teaching? 1. "I should consume less than 1 liter of fluid per day." 2. "I should use my treadmill or go for walks daily." 3. "I should follow moderate-calcium, high-fiber diet." 4. "My alendronate helps keep calcium from coming out of my bones."

1. "I should consume less than 1 liter of fluid per day." (Saunders)

The nurse is caring for a postoperative client who had a thyroidectomy. The client develops difficulty breathing from laryngospasms, muscular spasms, and twitching. Which medication should the nurse have available for emergency treatment in the client who has had a thyroidectomy? 1. Calcium chloride. 2. Potassium chloride. 3. Magnesium sulfate. 4. Propylthiouracil.

1. Calcium chloride. (Zerwekh)

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client has a flat affect but is irritable when questioned, has a poor memory, reports a loss of appetite, wants to sleep all the time, and doesn't care if she gets well. What collaborative action should the nurse take in response to this information? 1. Discuss with the HCP a concern for depression. 2. Request a neurology consult for a CT scan. 3. Discuss with the dietician a need for a nutritional consult. 4. Request a social service consult for home evaluation.

1. Discuss with the HCP a concern for depression. (Zerwekh)

A patient with a pituitary tumor is treated with a transsphenoidal hypophysectomy. What would be a priority postoperative action? 1. Ensure that any clear nasal drainage is tested for glucose. 2. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leak. 3. Assist the patient with tooth brushing to keep the surgical area clean. 4. Encourage deep breathing and coughing to prevent respiratory complications.

1. Ensure that any clear nasal drainage is tested for glucose. (Zerwekh)

The nurse is caring for a patient with thyroid disease who is experiencing a "racing heart," weight loss, exophthalmos, and heat intolerance. What additional actions should the nurse take? SATA. 1. Evaluate if the client is receiving a beta-blocker. 2. Assess for hypotension. 3. Request increased calories with three balanced meals a day. 4. Apply lubricating eyedrops throughout the day. 5. Place a circulating fan in the room.

1. Evaluate if the client is receiving a beta-blocker. 4. Apply lubricating eyedrops throughout the day. 5. Place a circulating fan in the room. (Zerwekh)

A client had a left modified radical mastectomy 48 hours ago. What would be important for the nurse to include in a discharge teaching plan for this client? SATA. 1. Massage wound site with essential oils once incision has healed. 2. Avoid needle-sticks in the left arm. 3. Begin active exercises, such as pendulum arm swings, immediately. 4. Avoid abduction and external rotation of the upper arm. 5. Elevate arm on pillows to prevent edema. 6. Take blood pressure readings from the right arm.

2. Avoid needle-sticks in the left arm. 5. Elevate arm on pillows to prevent edema. 6. Take blood pressure readings from the right arm. (Zerwekh)

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1. Placing cool compresses on the affected arm 2. Elevating the affected arm on a pillow above heart level 3. Avoiding arm exercises in the immediate postoperative period 4. Maintaining an intravenous site below the antecubital area on the affected side

2. Elevating the affected arm on a pillow above heart level (Saunders)

The nurse is discussing the importance of breast self-examination with a client who is being discharged after a vaginal hysterectomy. What is important information for the nurse to give to this client? 1. Perform BSE 1 week after her normal period. 2. Examine her breasts on a regular basis about the same time every month. 3. Breasts should be palpated while in the sitting position. 4. Use the tips of the fingers to palpate deeply into the breast tissue.

2. Examine her breasts on a regular basis about the same time every month. (Zerwekh)

After a tonic-clonic (formerly grand mal) seizure, what nursing action is the highest priority? 1. Loosen or remove constrictive clothing and protect client from injuring himself or herself. 2. Maintain a patent airway by turning the client on his side and suctioning, if necessary. 3. Remain with the client and administer anticonvulsant medications as ordered by the physician. 4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.

2. Maintain a patent airway by turning the client on his side and suctioning, if necessary. (Zerwekh)

The nurse is caring for a client postoperative thyroidectomy. What action should the nurse prioritize? SATA. 1. Have the client speak every 5 to 10 minutes if hoarseness is present. 2. Support the head with pillows and avoid flexion of the neck. 3. Check breath sounds for stridor. 4. Assess for tingling in the toes, fingers, and around the mouth or muscular twitching. 5. Assess every 4 hours for the first 24 hours for signs of hemorrhage. 6. Place with head of bed flat, in a side-lying position in case of vomiting.

2. Support the head with pillows and avoid flexion of the neck. 3. Check breath sounds for stridor. 4. Assess for tingling in the toes, fingers, and around the mouth or muscular twitching. (Zerwekh)

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. the nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? SATA. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3,4,5,6 (Saunders)

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glascow Coma Scale score of 15

3. A positive Brudzinski's sign (Saunders)

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hoarseness 2. Hypocalcemia 3. Audible stridor 4. Edema at the surgical site

3. Audible stridor (Saunders)

A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. Which assessment is most concerning? 1. Glucose of 70 mg/dL. 2. Potassium of 3.4 mEq/L. 3. Blood pressure of 169/98 mm Hg. 4. Sodium of 146 mEq/L.

3. Blood pressure of 169/98 mm Hg. (Zerwekh)

A client is prescribes levothyroxine daily. What should the nurse include in the discharge teaching? SATA. 1. Taper the dose, never stop abruptly. 2. Take it at bedtime to avoid the side effects. 3. Call the HCP if you experience palpitations or nervousness. 4. Decrease the intake of juices and fruits with high potassium and calcium contents. 5. Regular follow-up care will be required.

3. Call the HCP if you experience palpitations or nervousness. 5. Regular follow-up care will be required. (Zerwekh)

The nurse receives the new orders below for a client admitted in thyroid crisis. Which order should the nurse question? Jane Johnson MR: 96837 DOB: 6/5/1962 Allergies: NKDA Admission Orders - 5/20/19 1.) Admit to hospital for thyroid crisis 2.) Cardiac monitor continuous 3.) Hyperthermia blanket PRN 4.) IV fluids 0.9% 50 mL/hr X 1 liter 5.) Propranolol 6.) Propylthiouracil 7.) Stat T3, T4, and TSH serum level 1. IV fluids. 2. Serum blood tests. 3. Propylthiouracil 4. A hyperthermia blanket.

4. A hyperthermia blanket. (Zerwekh)

The nurse is caring for a client who has had a mastectomy. What is important nursing care regarding the positioning of the affected arm? 1. Hold the arm close against the side of the body. 2. Secure the arm below the level of the heart. 3. Wrap the arm in an elastic bandage and keep it below the heart. 4. Elevate the arm above heart level.

4. Elevate the arm above heart level. (Zerwekh)

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1. At the onset of menstruation 2. Every month during ovulation 3. Weekly at the same time of day 4. One week after menstruation begins

4. One week after menstruation begins (Saunders)

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. A. Hirsutism B. Menorrhagia C. Buffalo hump D. Dependent edema E. Migraine headaches

A. Hirsutism C. Buffalo hump

What clinical indicators should a nurse assess when caring for a client with hyperthyroidism? Select all that apply. A. Dry skin B. Weight loss C. Tachycardia D. Restlessness E. Constipation F. Exophthalmos

B. Weight loss C. Tachycardia D. Restlessness F. Exophthalmos

The urinalysis results of a female client shows the 17-ketosteroids value as 25 mg/24 hr. Which condition should the nurse monitor for in this client? A. Addison disease B. Ovarian neoplasms C. Ovarian dysfunction D. Cushing syndrome

D. Cushing syndrome (adaptive quiz)

2. While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"

a. "Have you noticed any blood in your stool?" (Giddens)

7. A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurse's next steps? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.

a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. (Giddens)

3. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep

a. Prioritization and administration of nursing care throughout the day (Giddens)

2. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition

a. Uninsured or underinsured status c. High cost of medications d. Inadequate nutrition (Giddens)

2. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be a. change in level of consciousness. b. inability to focus visually. c. loss of primitive reflexes. d. unequal pupil size.

a. change in level of consciousness. (Giddens)

3. When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. b. hypertension, and tachycardia. c. hypotension, and bradycardia. d. hypotension, and tachycardia.

a. hypertension, and bradycardia. (Giddens)

3. Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours (Giddens)

1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered

b. Clustering many nursing activities (Giddens)

7. After shunt procedure, the nurse would monitor the patient's neurologic status by using the a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine.

b. GCS. (Giddens)

1. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output

b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission e. Administration of intravenous fluids f. Strict monitoring of intake and output (Giddens)

1. The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

b. Using skin protection during sun exposure while at the beach (Giddens)

4. A nurse is teaching a group of businesspeople about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following? a. "When traveling outside of the country, I need to be sure that I receive appropriate vaccinations." b. "Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance." c. "If I don't feel sick, then I don't have to worry about transmitted diseases." d. "I need to be sure to have good hygiene practices when traveling in crowded planes and trains."

c. "If I don't feel sick, then I don't have to worry about transmitted diseases." (Giddens)

2. While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of a _____ infection. a. bacterial b. fungal c. parasitic d. viral

c. parasitic (Giddens)

1. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a a. host. b. mode of transmission. c. portal of entry. d. reservoir

c. portal of entry. (Giddens)

5. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a 75-year-old woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age

d. Advancing age (Giddens)

6. In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.

d. Instruct the patient to cough and deep breathe. (Giddens)

4. The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

d. Mild temperature elevation (Giddens)

4. Components of the GCS the nurse would use to assess a patient after a head injury include a. blood pressure. b. cranial nerve function. c. head circumference. d. verbal responsiveness.

d. verbal responsiveness. (Giddens)

5. Primary prevention strategies to reduce the occurrence of head injuries would include a. blood pressure control. b. smoking cessation. c. maintaining a healthy weight. d. violence prevention.

d. violence prevention. (Giddens)

5. In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify a. whether a patient has an infection. b. where an infection is located. c. what cells are being utilized by the body to attack an infection. d. what specific type of pathogen is causing an infection.

d. what specific type of pathogen is causing an infection. (Giddens)