Test 5- NUR111

For a client with the diagnosis of bulimia nervosa, purging type, which clinical manifestation would be monitored? a. Weight gain b. Dehydration c. Hyperactivity d. Hyperglycemia

b. Dehydration

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

b. Drainage from a T-tube

16. The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? a. Skin condition b. Fluid and electrolyte balance c. Food intake d. Fluid intake and output

b. Fluid and electrolyte balance

A client is receiving furosemide. For which sign of hypokalemia will the nurse monitor the client? a. Chvostek sign b. Muscle weakness c. Anxious behavior d. Abdominal cramping

b. Muscle weakness

What assessment does a nurse make before handing an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

1. Urine output 4. Serum potassium laboratory value in EHR

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) 1. With whom do you take on a routine basis? 2. What do you do when you feel lonely? 3. Tell me what your husband was like? 4. I know this must be hard for you. Let me tell you what might help. 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

1. With whom do you take on a routine basis? 2. What do you do when you feel lonely? 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking

The nurse is reviewing the laboratory reports of a group of older adult clients. Which client has an age- related impairment of the thirst mechanism? A 167 mEq/L B 143 mEq/L C 118 mEq/L D 101 mEq/ L

A 167 mEq/L

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this is _______.

Post-traumatic stress disorder (PTSD)

The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia

a. Hypokalemia

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor with laboratory results? a. Sodium and chloride levels b. Bicarbonate and sulfate levels c. Magnesium and protein levels d. Calcium and phosphate levels

a. Sodium and chloride levels

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

b. Serum potassium level

A client arrives at the emergency department reporting minimal urinary output despite drinking adequate fluid. The client blood pressure is 190/94 mm Hg. Which additional clinical manifestation would the nurse assess the client for? a. Thirst b. Weight gain c. Urinary retention d. Urinary hesitancy

b. Weight gain

Which clinical sign is the most important indication of an accurate degree of dehydration? a. Dry skin b. Weight loss c. Sunken fontanel d. Decreased urine output

b. Weight loss

The nurse gave a client the prescribed sodium polystyrene sulfonate. Which assessment finding indicates that the medication has been effective? a. Control of diarrhea b. An increase in serum sodium level c. An increase in serum calcium level d. A decrease in serum potassium level

d. A decrease in serum potassium level

Which clinical manifestations would the nurse identify when assessing a client with hypercalcemia? Select all that apply. One, some, or all responses may be correct. a. Muscle tremors b. Abdominal cramps c. Increased peristalsis d. Cardiac dysrhythmias e. Hypoactive bowel sounds

d. Cardiac dysrhythmias e. Hypoactive bowel sounds

Which clinical finding would the nurse associate with hypokalemia? a. Edema b. Muscle spasms c. Kussmaul respirations d. Muscle weakness

d. Muscle weakness

The nurse administers sodium polystyrene sulfonate to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? a. Pruritus decreases b. Mental status improves c. Sodium decreases to 137 mEq/L (137 mmol/L) d. Potassium decreases to 4.2 mEq/L (4.2 mmol/L)

d. Potassium decreases to 4.2 mEq/L (4.2 mmol/L)

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1. Denial 2. Conversion 3. Dissociation 4. Displacement

1. Denial

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 4. Monitoring for constipation

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) 1. Referral to social service process reestablishing the child's disability payment 2. Sending the child home in 72 hours and having the child return to school 3. Coordinating hospital- based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection 5. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

1. Referral to social service process reestablishing the child's disability payment 3. Coordinating hospital- based and home-based schooling with the child's teacher 4. Teaching the mother signs and symptoms of a respiratory tract infection

An older adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify the health care provider 2. Decrease the IV flow rate 3. Lower the head of the bed 4. Discontinue the IV site

2. Decrease the IV flow rate

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two- thirds of the volume 2. One- half of the volume 3. One- quarter of the volume 4. Two times the volume

2. One- half of the volume

The nurse plans care for a 16- year- old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply) 1. Loss of autonomy caused by health problems 2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

2. Physical appearance and body image 3. Accepting one's personal identity 4. Separation from family 5. Taking tests in school

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply) 1. "I'm going to learn to drive a car, so I can be more independent." 2. "My sister says she feels better when she goes shopping, so I'll go shopping." 3. "I'm going to let the occupational therapist assess my home to improve efficiency." 4. "I've always felt better when I go for a long walk. I'll do that when I get home." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

3. "I'm going to let the occupational therapist assess my home to improve efficiency." 5. "I'm going to attend a support group to learn more about multiple sclerosis."

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? 1. The amount of family support 2. A 3- day diet recall 3. A thorough physical assessment 4. Threats to safety in her home

3. A thorough physical assessment

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she intermittently homeless, a single parent with two children who have developed developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) 1. post-traumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

3. Chronic illness 4. Insomnia 5. Depression

Which assessment does the nurse use a clinical marker for vascular volume in a patient at high risk for extracellular fluid volume (ECV) deficit? 1. Dry of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

A 34- year- old single father who is anxious, tearful, and tired from caring for his three children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer?"

4. "Tell me what you mean when you say you can't go on any longer?"

When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. a. Oliguria b. Dyspnea c. Hypotension d. Pulmonary crackles e. Tenting skin turgor

A. oliguria C. hypotension E. tenting skin turgor

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? a. Rapid, thready pulse b. Distended jugular veins c. Elevated hematocrit level d. Increased serum sodium levels

B. Distended jugular veins

A client develops an intestinal obstruction. A nasogastric tube is inserted and connected to low, continuous suction. The nurse monitors the client for fluid volume deficit. Which clinical finding would the nurse expect if the client become dehydrated? a. Restlessness b. Constipation c. Inelastic skin turgor d. Increased blood pressure

C. Inelastic skin turgor

The nurse assesses pain and redness at the vascular access device (VAD) site. Which action is taken first? a. Apply a warm, moist compress b. Aspirate the infusing fluid from the VAD c. Report the situation to the health care provider d. Discontinue the intravenous infusion

D. Discontinue the intravenous infusion

Which serum hormone level elevates in response to a client's total serum calcium concentration of 7.9 mg/dL (0.43 mmol/L)? a. Estrogen b. Thyroxine C. Growth hormone D. Parathyroid hormone (PTH)

D. Parathyroid hormone (PTH)

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L), and the potassium level is 3.0 MEq/L (3.0 mmol/L). The nurse notifies the primary health care provider. Which prescription would the nurse be prepared to administer? a. Add potassium chloride (KCL) to the existing intravenous (IV) lactated Ringer solution. b. Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. c. Discontinue the IV NaCl with 20 mEq KCI solution and replace with IV 5% dextrose in water (D5W) solution. D5W d. Discontinue the IV 5% D5W with 40 mEq KCI solution and replace with IV 5% solution

a. Add potassium chloride (KCL) to the existing intravenous (IV) lactated Ringer solution.

The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? a. Administering sodium polystyrene sulfonate b. Instructing a client to increase potassium and sodium intake c. Monitoring glucose levels hourly d. Providing potassium- sparing diuretics

a. Administering sodium polystyrene sulfonate

The nurse identifies that a client's urinary output is less that 40 mL/h over the past 3 hours. Which action would the nurse take? a. Assess breath sounds and obtain vital signs b. Decrease the intravenous flow rate and increase oral fluids c. Insert an indwelling catheter to facilitate emptying of the bladder d. Check for dependent edema by assessing the lower extremities

a. Assess breath sounds and obtain vital signs

. Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct. a. Bone pain b. Convulsions c. Muscle spasms d. Tingling of extremities e. Depressed deep tendon reflexes

a. Bone pain e. Depressed deep tendon reflexes

Which finding would the nurse anticipate when reviewing the laboratory reports of a client with an acute kidney injury? Select all that apply. One, some, or all responses may be correct. a. Calcium: 7.6 mg/dL (1.9 mmol/L) b. Calcium: 10.5 mg/ dL (2.6 mmol/L) c. Potassium: 6.0 mEq/L (6.0 mmol/L) d. Potassium: 3.5 mEq/L (3.5 mmol/L) e. Creatinine: 3.2 mg/dL (194 mmol/ L) f. Creatinine: 1.1 mg/dL (90 mmol/L)

a. Calcium: 7.6 mg/dL (1.9 mmol/L) c. Potassium: 6.0 mEq/L (6.0 mmol/L) e. Creatinine: 3.2 mg/dL (194 mmol/ L)

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? a. Clear breath sounds b. Positive pedal pulses c. Normal potassium level d. Decreased urine specific gravity

a. Clear breath sounds

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload. a. Crackles in the lungs b. Decreased heart rate c. Decreased blood pressure d. Cyanosis of nail beds

a. Crackles in the lungs

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct. a. Decreased urine b. Hypotension c. Dyspnea d. Dry mucous membranes e. Lung crackles f. Poor skin turgor

a. Decreased urine b. Hypotension d. Dry mucous membranes F. Poor Skin Turgor

Intravenous (IV) potassium is prescribed for a client with a diagnosis of hypokalemia. Which statement about administration of IV potassium is accurate? a. Oliguria is an indication for withholding IV potassium b. Rapid infusion of potassium prevents burning at the IV site c. Clients with severe deficits should be given IV push potassium d. Average IV dosage of potassium should not exceed 60 mEq in 1 hour

a. Oliguria is an indication for withholding IV potassium

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? a. Weighing the client b. Monitoring the intake and output c. Assessing the extent of pitting edema d. Asking client about subjective symptoms

a. Weighing the client

A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. a. Wound drainage b. Diuretic therapy c. Gastrointestinal (GI) suction d. Parenteral infusion of 0.9% sodium chloride e. Inappropriate antidiuretic hormone (ADH) secretion

a. Wound drainage b. Diuretic therapy c. Gastrointestinal (GI) suction e. Inappropriate antidiuretic hormone (ADH) secretion

The nurse is providing care for a client who is hospitalized for dehydration and expects which assessment findings? Select all that apply. One, some or all responses may be correct. a. Protruding eyeballs b. Postural hypotension c. The client reports eating an average of two meals daily d. The skin on the client's forehead remains tented after being pinched e. Within 4 days, the client lost 4 ounces (0.11kg) of weight

b. Postural hypotension d. The skin on the client's forehead remains tented after being pinched e. Within 4 days, the client lost 4 ounces (0.11kg) of weight

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct. a. Supple skin turgor b. Rapid, thready pulse c. Decreased hematocrit d. Elevated specific gravity e. Adventitious breath sounds

b. Rapid, thready pulse d. Elevated specific gravity

When a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks, which assessment is the priority? a. Palpate the abdomen b. Check for ankle edema c. Auscultate breath sounds d. Ask about dietary salt intake

c. Auscultate breath sounds

When caring for a client who has hyponatremia, the nurse would monitor for which symptom? a. Increased urine output b. Deep rapid respirations c. Change in level of consciousness d. Distended neck veins

c. Change in level of consciousness

The nurse assesses an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? a. Sunken eyes b. Dry, flaky skin c. Change in mental status d. Decreased bowl sounds

c. Change in mental status

Which disease increases the risk of hyperkalemia? a. Chron disease b. Cushing disease c. End-stage renal disease d. Gastroesophageal reflux disease

c. End-stage renal disease

A client is taking furosemide. At each clinic visit, the nurse will assess for which adverse effect? a. Rapid weight loss b. Xanthopsia c. Hyporeflexia d. Bronchospasm

c. Hyporeflexia

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. a. Diplopia b. Skin rash c. Leg cramps d. Tachycardia e.Muscle weakness

c. Leg cramps E. Muscle cramps

Which clinical manifestation will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L (6.4 mmol/L)? Select all that apply. One, some, or all responses may be correct. a. Anorexia b. Constipation c. Muscle weakness d. Irregular health rhythm e. Hyperactive bowl tones

c. Muscle weakness d. Irregular health rhythm e. Hyperactive bowl tones

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily based metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next? a. Send another blood sample to the laboratory to retest the serum potassium level b. Notify the health care provider that the potassium level is above normal c. Notify the health care provider that the potassium level is below normal d. No action is required because that potassium level is within normal limits

c. Notify the health care provider that the potassium level is below normal

An older client is admitted to hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? a. Calcium b. Chlorides c. Potassium d. Phosphates

c. Potassium

The nurse identifies a disease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for great concern for this client? a. Calcium b. Chloride c. Potassium d. Phosphate

c. Potassium

The nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. Which serum blood level would the nurse monitor? a. Urea b. Chloride c. Potassium d. Creatinine

c. Potassium

An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value would the nurse report to the health care provider? a. Sodium of 140 mEq/L (140mmol/L) b. Ionized calcium of 2.35 mEq/L (1.2 mmol/L) c. Chloride of 102 mEq/L (102 mmol/L) d. Potassium of 3.0 mEq/L (3.0 mmol/L)

d. Potassium of 3.0 mEq/L (3.0 mmol/L)