Evolve Med Surg Practice 123 Questions with Verified Answers
Which description of symptoms is characteristic of a client diagnosed with trigeminal
... [Show More] neuralgia (tic douloureux)?
A) Tinnitus, vertigo, and hearing difficulties.
B) Sudden, stabbing, severe pain over the lip and chin.
C) Facial weakness and paralysis.
D) Difficulty in chewing, talking, and swallowing. - CORRECT ANSWER B) Sudden, stabbing, severe pain over the lip and chin.
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) (B). (A) would be characteristic of Méniére's disease (8th cranial nerve). (C) would be characteristic of Bell's palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal cranial nerve (12th).
A 67-year-old woman who lives alone is admitted after tripping on a rug in her home and fractures her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?
A) Failing eyesight resulting in an unsafe environment.
B) Renal osteodystrophy resulting from chronic renal failure.
C) Osteoporosis resulting from hormonal changes.
D) Cardiovascular changes resulting in small strokes which impair mental acuity. - CORRECT ANSWER C) Osteoporosis resulting from hormonal changes.
The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in later life (C). (A) may or may not have contributed to the accident, but it had nothing to do with the hip being involved. (B) is not a common condition of the elderly; it is common in chronic renal failure. (D) may occur in some people, but does not affect the fragility of the bones as osteoporosis does.
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first?
A) Place a chair at a right angle to the bedside.
B) Encourage deep breathing prior to standing.
C) Help the client to sit and dangle legs on the side of the bed.
D) Allow the client to sit with the bed in a high Fowler's position. - CORRECT ANSWER D) Allow the client to sit with the bed in a high Fowler's position.
The first step is to raise the head of the bed to a high Fowler's position (D), which allow venous return to compensate from lying flat and vasodilating effects of perioperative drugs. (A, B, and C) are implemented after (D).
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
A) Check it again in one month, and if it is still there schedule an appointment.
B) Most lumps are benign, but it is always best to come in for an examination.
C) Try not to worry too much about it, because usually, most lumps are benign.
D) If you are in your menstrual period it is not a good time to check for lumps. - CORRECT ANSWER B) Most lumps are benign, but it is always best to come in for an examination.
(B) provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. (A) postpones treatment if the lump is malignant, and does not relieve the client's anxiety. (C and D) provide false reassurance and do not help relieve anxiety.
A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
A) Notify social services immediately of suspected elderly abuse.
B) Discuss the need for mental health counseling with the daughter.
C) Explain to the client that she needs to take better care of herself.
D) Collect further data to determine whether self-neglect is occurring. - CORRECT ANSWER D) Collect further data to determine whether self-neglect is occurring.
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed (D) before notifying social services (A) or discussing a need for counseling (B). Until further information is obtained, explanations about the client's needs are premature (C).
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect this client to exhibit?
A) Elevated LDH.
B) Elevated serum amylase.
C) Elevated CK-MB.
D) Elevated hematocrit. - CORRECT ANSWER C) Elevated CK-MB.
The cardiac isoenzyme CK-MB (C) is the most sensitive and most reliable indicator of myocardial damage of all the cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac enzyme that peaks around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be expected in a client with a fluid volume deficit, which is not a typical finding in MI.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength. - CORRECT ANSWER A) Prevention of deformities.
Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's
A) serum digoxin level is 1.5.
B) blood pressure is 104/68.
C) serum potassium level is 3.
D) apical pulse is 68/min. - CORRECT ANSWER C) serum potassium level is 3.
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
A) Use a laryngoscope to check for a foreign body lodged in the esophagus.
B) Reposition the head to validate that the head is in the proper position to open the airway.
C) Turn the client to the side and administer three back blows.
D) Perform a finger sweep of the mouth to remove any vomitus. - CORRECT ANSWER B) Reposition the head to validate that the head is in the proper position to open the airway.
The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the airway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?
A) Black.
B) White.
C) Light green.
D) Medium yellow. - CORRECT ANSWER D) Medium yellow.
Yellow is the easiest for a person with failing vision to see (D). (A) will be almost impossible to see at night because the shadows of the steps will be too difficult to determine, and would pose a safety hazard. (B) is very hard to see with a glare from the sun and it could hurt the eyes in the daytime to look at them. (C) is a pastel color and is difficult for elderly clients to see.
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A) Cyanosis of the fingertips.
B) Bradycardia and bradypnea.
C) Presence of S3 and S4 heart sounds.
D) 3+ pitting edema of the lower extremities. - CORRECT ANSWER A) Cyanosis of the fingertips.
Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands (A) which may lead to gangrene. (B, C, and D) are abnormal findings, but do not indicate the development of septic emboli.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
A) Sodium.
B) Antidiuretic hormone.
C) Potassium.
D) Glucose. - CORRECT ANSWER C) Potassium.
Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia)--hypertension is the most prominent and universal sign. (A) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (B) is decreased with diabetes insipidus. (D) is not affected by primary aldosteronism.
A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?
A) Fluid and electrolyte balance.
B) Prevention of water toxicity.
C) Reduced glucose in the urine.
D) Adequate cellular nourishment. - CORRECT ANSWER D) Adequate cellular nourishment.
Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy, so the outcome statement should include stabilization of adequate cellular nutrition (D). (A, B, and C) relate to subsequent osmolar fluid shifts related to glucosuria, polyuria, and polydipsia.
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol?
A) Diuretic therapy.
B) Pacemaker implantation.
C) Anticoagulation therapy.
D) Cardiac catheterization. - CORRECT ANSWER C) Anticoagulation therapy.
The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. (A, B, and D) are not indicated.
Which information about mammograms is most important to provide a post-menopausal female client?
A) Breast self-examinations are not needed if annual mammograms are obtained.
B) Radiation exposure is minimized by shielding the abdomen with a lead-lined apron.
C) Yearly mammograms should be done regardless of previous normal x-rays.
D) Women at high risk should have annual routine and ultrasound mammograms. - CORRECT ANSWER C) Yearly mammograms should be done regardless of previous normal x-rays.
The current breast screening recommendation is a yearly mammogram after age 40 (C). Breast self-exam (A) continues to be a priority recommendation for all women because a small lump (or tumor) is often first felt by a woman before a mammogram is obtained. The radiation exposure from a mammogram is low, so (B) is not normally provided. The frequency of using routine and ultrasound mammograms (D) in women with high-risk variables, such as a history of breast cancer, the presence of BRC1 and BRC2 genes, or 2 first-degree relatives with breast cancer, should be recommended and followed closely by the healthcare provider.
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
A) A 35-year-old multipara who never breastfed.
B) A 50-year-old whose mother had unilateral breast cancer.
C) A 55-year-old whose mother-in-law had bilateral breast cancer.
D) A 20-year-old whose menarche occurred at age 9. - CORRECT ANSWER B) A 50-year-old whose mother had unilateral breast cancer.
The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause. Although all of the women described have one of the risk factors for developing breast cancer, (B) has the greater risk over (A, C, and D).
A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?
A) Stay out of direct sunlight.
B) Restrict intake of high protein foods.
C) Schedule extra rest periods.
D) Go to the emergency room immediately. - CORRECT ANSWER C) Schedule extra rest periods.
Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. Extra rest periods should be scheduled (C) to reduce the symptoms. (A, B, and D) are not necessary.
Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system?
A) Pupil constriction.
B) Increased heart rate.
C) Bronchial constriction.
D) Decreased blood pressure. - CORRECT ANSWER B) Increased heart rate.
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a flight-or-fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system.
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency?
A) K.
B) B12.
C) B6.
D) C. - CORRECT ANSWER A) K.
Clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency (A). These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K. (B, C, and D) are not fat soluble vitamins.
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client?
A) Situational low self-esteem related to functional impairment and change in role function.
B) Disabled family coping related to dissonant coping style of significant person.
C) Interrupted family processes related to shift in health status of family member.
D) Risk for ineffective therapeutic regimen management related to complexity of care. - CORRECT ANSWER B) Disabled family coping related to dissonant coping style of significant person.
A stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to the client's care. Her help is noted as being incongruent with attempts of self-care by the client thereby disabling family coping (B). The scenario does not discuss the client's self-esteem (A), interrupted family processes (C) or the risk for ineffective therapeutic regimen (D).
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
A) Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
B) Purse the lips while inhaling as deeply as possible and then exhale through the nose.
C) Wrap a towel around the abdomen and push against the towel while forcefully exhaling.
D) Place one hand on the chest, one hand the abdomen and make both hands move outward. - CORRECT ANSWER A) Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so (A) helps the client visualize the rise and fall of the abdomen. The client should purse the lips while exhaling, not (B). (C and D) are ineffective.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
A) He visits his diabetic brother who just had surgery to amputate an infected foot.
B) He is provided with the most current information about the dangers of untreated diabetes.
C) He comments on the community service announcements about preventing complications associated with diabetes.
D) His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. - CORRECT ANSWER A) He visits his diabetic brother who just had surgery to amputate an infected foot.
The loss of a limb by a family member (A) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (B, C, and D) may influence his behavior but do not have the personal impact of (A).
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?
A) 15 minutes before and 15 minutes after the next dose.
B) One hour before and one hour after the next dose.
C) 5 minutes before and 30 minutes after the next dose.
D) 30 minutes before and 30 minutes after the next dose. - CORRECT ANSWER C) 5 minutes before and 30 minutes after the next dose.
Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have?
A) Racing pulse with exertion.
B) Clubbing of the fingers.
C) An increased chest diameter.
D) Productive cough with grayish-white sputum. - CORRECT ANSWER D) Productive cough with grayish-white sputum.
Chronic bronchitis, one of the diseases comprising the diagnosis of COPD, is characterized by a productive cough with grayish-white sputum (D), which usually occurs in the morning and is often ignored by smokers. (A) is not related to chronic bronchitis; however, it is indicative of other problems such as ventricular tachycardia and should be explored. (B and C) are symptoms of emphysema and are not consistent with the other symptoms. (C) is usually referred to as a "barrel chest."
What discharge instruction is most important for a client after a kidney transplant?
A) Weigh weekly.
B) Report symptoms of secondary Candidiasis.
C) Use daily reminders to take immunosuppressants.
D) Stop cigarette smoking. - CORRECT ANSWER C) Use daily reminders to take immunosuppressants.
After renal transplantation, acute rejection is a risk for several months, so immunosuppressive therapy, such as corticosteroids and azathioprine (Imuran), is essential in preventing rejection, so the priority instruction includes measures, such as daily reminders (C), to ensure the client takes these medications regularly. Daily weights, not weekly (A), provides a better indicator of weight gain related to rejection. Although fungal infections related to the immunosuppression should be reported (B), it is more important to ensure medication compliance to prevent rejection. Although smoking (D) increases the risk of atherosclerotic vascular disease which is common in clients with an organ transplant, (C) remains the priority.
A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client?
A) Xylocaine (Lidocaine).
B) Procainamide (Pronestyl).
C) Phenytoin (Dilantin).
D) Digoxin (Lanoxin). - CORRECT ANSWER D) Digoxin (Lanoxin).
Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output. (A, B, and C) are not indicated in the initial treatment of uncontrolled atrial fibrillation.
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
A) Observe cyst size fluctuations as a sign of malignancy.
B) Use estrogen supplements to reduce breast discomfort.
C) Notify the healthcare provider if whitish nipple discharge occurs.
D) Perform a breast self-exam (BSE) procedure monthly. - CORRECT ANSWER D) Perform a breast self-exam (BSE) procedure monthly.
Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE (D) and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen (B), which is not indicated. Nipple discharge associated with fibrocystic breasts is often milky or watery-milky and is an expected finding (C).
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?
A) Report the findings to the surgeon.
B) Irrigate the indwelling urinary catheter.
C) Apply manual pressure to the bladder.
D) Increase the IV flow rate for 15 minutes. - CORRECT ANSWER A) Report the findings to the surgeon.
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare provider.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding should the nurse expect this client to exhibit?
A) A decreased total lung capacity.
B) Normal arterial blood gases.
C) Normal skin coloring.
D) An absence of sputum. - CORRECT ANSWER C) Normal skin coloring.
The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations) (C). Total lung capacity is increased in emphysema since these clients have hyperinflated lungs (A). Arterial blood gases are typically abnormal (B). (D) is indicative of bronchitis, while clients with emphysema usually have copious amounts of thick, white sputum.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's
A) pulse rate, both apically and radially.
B) blood pressure, both standing and sitting.
C) temperature.
D) skin color and turgor. - CORRECT ANSWER C) temperature.
It is very important to check the client's temperature (C). Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of corticosteroids are particularly predisposed to infection. (A and B) are important data for baseline and ongoing assessment, but they are not as important as temperature measurement for this client who is taking steroids. Assessment of skin color and turgor is less important (D).
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?
A) Maintain the residual limb on three pillows at all times.
B) Place a large tourniquet at the client's bedside.
C) Apply constant, direct pressure to the residual limb.
D) Do not allow the client to lie in the prone position. - CORRECT ANSWER B) Place a large tourniquet at the client's bedside.
A large tourniquet should be placed in plain sight at the client's bedside (B). If severe bleeding occurs, the tourniquet should be readily available and applied to the residual limb to control hemorrhage. The residual limb should not be placed on a pillow (A) because a flexion contracture of the hip may result. (C) should be avoided because it may compromise wound healing. (D) should be encouraged to stretch the flexor muscles and to prevent flexion contracture of the hip.
An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client is most likely to reveal which sign/symptom?
A) Leukocytosis and febrile.
B) Polycythemia and crackles.
C) Pharyngitis and sputum production.
D) Confusion and tachycardia. - CORRECT ANSWER D) Confusion and tachycardia.
The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia.
The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide?
A) This recessive disorder is carried only on the X chromosome.
B) Occurrences mainly affect males and heterozygous females.
C) Both genes of a pair must be abnormal for the disorder to occur.
D) One copy of the abnormal gene is required for this disorder. - CORRECT ANSWER C) Both genes of a pair must be abnormal for the disorder to occur.
Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A and B) dominant or recessive disorder or an autosomal dominant inheritance disorder. Both genes of a pair, not (D), must be present.
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
A) Serum PTT of 10 seconds.
B) Serum calcium of 5 mg/dl.
C) Oxygen saturation of 90%.
D) Hemoglobin of 10 g/dl. - CORRECT ANSWER B) Serum calcium of 5 mg/dl.
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS.
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client?
A) Facial flushing.
B) Fever.
C) Pounding headache.
D) Feelings of dizziness. - CORRECT ANSWER D) Feelings of dizziness.
Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output (D). (A and C) will not occur as the result of pacemaker failure. (B) may be an indication of infection postoperatively, but is not an indication of pacemaker failure.
A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?
A) Osteoporosis is a progressive genetic disease with no effective treatment.
B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
C) Estrogen replacement therapy should be started to prevent the progression osteoporosis.
D) Low-dose corticosteroid treatment effectively halts the course of osteoporosis. - CORRECT ANSWER B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can prevent further bone loss (B). Osteoporosis can be managed with conservative therapy, such as bone metabolism regulators and estrogen replacement therapy (ERT) to improve bone density, but it is not a genetic disease (A). Although ERT is effective in managing osteoporosis, an increased risk for cancer and heart disease should be considered for individual clients. Corticosteroid therapy promotes bone resorption and is counterproductive in maintaining or increasing bone density (D).
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?
A) The dosage of the diuretic will be decreased.
B) The diuretic will be discontinued.
C) A potassium supplement will be prescribed.
D) The dosage of the diuretic will be increased. - CORRECT ANSWER C) A potassium supplement will be prescribed.
This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level (C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.
The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?
A) Increase the amount of calcium intake in the diet.
B) Apply alternating heat and cold therapies.
C) Initiate a weight-reduction diet to achieve a healthy body weight.
D) Use a walker for ambulation to lessen weight-bearing on the hips. - CORRECT ANSWER C) Initiate a weight-reduction diet to achieve a healthy body weight.
Achieving a healthy weight (C) is critical to protect the joints of clients with OA. Increasing the amount of calcium in the client's diet (A) will not protect hip joints from the effects of OA. Thermal therapies may lessen pain and stiffness from OA but are not protective of the joints (B). Assistive devices such as a walker may be beneficial to help avoid falls and assist in ambulation but are not protective against OA's effects (D).
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?
A) A diet low in phosphates.
B) Skin inspection for bruising.
C) Exercise regimen, including swimming.
D) Elimination of hazards to home safety. - CORRECT ANSWER D) Elimination of hazards to home safety.
Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures can be given (D). A low phosphorus diet is not recommended in the treatment of osteoporosis (A). Bruising (B) is not a related symptom to osteoporosis. Weight-bearing exercise is most beneficial for clients with osteoporosis. Swimming (C) is not a weight-bearing exercise.
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client?
A) What dose of medication are you taking?
B) Are you eating foods rich in potassium?
C) Have you lost weight recently?
D) At what time do you take your medication? - CORRECT ANSWER D) At what time do you take your medication?
The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to insomnia.
The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A) Increased WBC, decreased RBC.
B) Increased serum bilirubin, slightly increased liver enzymes.
C) Increased protein in the urine, slightly increased serum glucose levels.
D) Decreased serum sodium, an increased urine specific gravity. - CORRECT ANSWER C) Increased protein in the urine, slightly increased serum glucose levels.
In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.
Which client should the nurse recognize as most likely to experience sleep apnea?
A) Middle-aged female who takes a diuretic nightly.
B) Obese older male client with a short, thick neck.
C) Adolescent female with a history of tonsillectomy.
D) School-aged male with a history of hyperactivity disorder. - CORRECT ANSWER B) Obese older male client with a short, thick neck.
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea.
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
A) She sustained an insect bite to her left arm yesterday.
B) She has lost twenty pounds since the surgery.
C) Her healthcare provider now prescribes a calcium channel blocker for hypertension.
D) Her hobby is playing classical music on the piano. - CORRECT ANSWER A) She sustained an insect bite to her left arm yesterday.
A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
A) I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
B) I will let you have one cracker, but that is all you can have for the rest of tonight.
C) What did the healthcare provider tell you about the test you are having tomorrow?
D) The test you are having tomorrow requires that you have nothing by mouth tonight. - CORRECT ANSWER D) The test you are having tomorrow requires that you have nothing by mouth tonight.
(D) is the most therapeutic statement because the nurse is responding to the client's question. (A) is not an explanation and the nurse should teach the client why eating is prohibited after midnight, rather than enforcing this requirement without an explanation for it. (B) may result in an inaccurate test result, or may cause the test to be cancelled, which could also delay diagnosis and treatment. (C) defers the responsibility for answering the client's question to the healthcare provider, when the nurse could address the situation through client teaching.
The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client's wound is infected. - CORRECT ANSWER D) If the client's wound is infected.
Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most important to place an infected client in a private room (D). A penrose drain does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a dead space and is not important in choosing a room.
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.)
A) Remove the diaphragm immediately after intercourse.
B) Wash the diaphragm with an alcohol solution.
C) Use the diaphragm to prevent conception during the menstrual cycle.
D) Do not leave the diaphragm in place longer than 8 hours after intercourse.
E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears.
F) Replace the old diaphragm every 3 months. - CORRECT ANSWER D) Do not leave the diaphragm in place longer than 8 hours after intercourse.
E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears.
Correct selections are (D and E). The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours (D) to avoid the risk of TSS. If a sudden fever occurs, the client should notify the healthcare provider (E). (A) increases the risk of pregnancy, and (B) can reduce the integrity of the barrier contraceptive but neither prevents the risk of TSS. The diaphragm should not be used during menses (C) because it obstructs the menstrual flow and is not indicated because conception does not occur during this time. (F) is not necessary.
A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?
A) The vaccine is given annually before the flu season to those over 50 years of age.
B) The immunization is administered once to older adults or persons with a history of chronic illness.
C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.
D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. - CORRECT ANSWER B) The immunization is administered once to older adults or persons with a history of chronic illness.
It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re-vaccination is sometimes required.
The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit?
A) Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
B) Shuffling gait, masklike facial expression, and tremors of the head.
C) Extreme muscular weakness, easy fatigability, and ptosis.
D) Numbness of the extremities, loss of balance, and visual disturbances. - CORRECT ANSWER B) Shuffling gait, masklike facial expression, and tremors of the head.
(B) are common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis.
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide?
A) Estrogen deficiency causes the vaginal tissues to become dry and thinner.
B) Infrequent intercourse results in the vaginal tissues losing their elasticity.
C) Dehydration from inadequate fluid intake causes vulva tissue dryness.
D) Lack of adequate stimulation is the most common reason for dyspareunia. - CORRECT ANSWER A) Estrogen deficiency causes the vaginal tissues to become dry and thinner.
Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier (A), and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. Dyspareunia is not related to (B or C). While (D) can contribute to discomfort during intercourse, the primary cause is hormone-related.
An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?
A) Regenerative function of the skin is absent because the dermal layer has been destroyed.
B) Tissue regeneration will begin several days following return of normal circulation.
C) Debridement of eschar will delay the body's ability to regenerate normal tissue.
D) Normal tissue formation will be preceded by scar formation for the first year. - CORRECT ANSWER A) Regenerative function of the skin is absent because the dermal layer has been destroyed.
Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary (A). (B, C, and D) are simply false.
Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma?
A) Numbness, tingling, and cramps in the extremities.
B) Headache, diaphoresis, and palpitations.
C) Cyanosis, fever, and classic signs of shock.
D) Nausea, vomiting, and muscular weakness. - CORRECT ANSWER B) Headache, diaphoresis, and palpitations.
(B) is the typical triad of symptoms of tumors of the adrenal medulla (symptoms depend on the relative proportions of epinephrine and norepinephrine secretion). (A) lists the signs of latent tetany, exhibited by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)
A) Set the infusion pump to infuse the albumin within four hours.
B) Compare the client's blood type with the label on the albumin.
C) Assign a UAP to monitor blood pressure q15 minutes.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration. - CORRECT ANSWER A) Set the infusion pump to infuse the albumin within four hours.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin administration does not require blood typing (B). Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding (F).
Physical examination of a comatose client reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding?
A) A cerebral infectious process is causing the posturing.
B) Severe dysfunction of the cerebral cortex has occurred.
C) There is a probable dysfunction of the midbrain.
D) The client is exhibiting signs of a brain tumor. - CORRECT ANSWER B) Severe dysfunction of the cerebral cortex has occurred [Show Less]