HESI 102 HESI Comprehensive Exit Exam 6 Spring 2022 Questions and Answers- Chamberlain College of Nursing
HES
I COMP
HESI Comprehensive Exit
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Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours
(ANS- Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. One common side effect is postural hypotension.
Therefore the nurse would check the client's blood pressure immediately before
administering each dose. Checking the client's peripheral pulses, the results of the
most recent potassium level, and the intake and output for the previous 24 hours
are not specifically associated with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client
indicates a need for further instruction?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have
to drink for the test can be constipating."
(ANS- "I need to drink citrate of magnesia the night before the test and give myself
a Fleet enema on the morning of the test."
Rationale: No special preparation is necessary before a GI series, except that NPO
(nothing by mouth) status must be maintained for 8 hours before the test. An upper
GI series involves visualization of the esophagus, duodenum, and upper jejunum
by means of the use of a contrast medium. It involves swallowing a contrast
medium (usually barium), which is administered in a flavored milkshake. Films are
taken at intervals during the test, which takes about 30 minutes. After an upper GI
series, the client is prescribed a laxative to hasten elimination of the barium.
Barium that remains in the colon may become hard and difficult to expel, leading
to fecal impaction.
A nurse on the evening shift checks a primary health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the normal dose.
The nurse calls the primary health care provider's answering service and is told that
the primary health care provider is off for the night and will be available in the
morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in
the morning
Administer the medication but consult the primary health care provider when he
becomes available
(ANS- Ask the answering service to contact the on-call primary health care
provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who
believes that a primary health care provider's prescription may be in error is
responsible for clarifying the prescription before carrying it out. Therefore the
nurse would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next
morning to obtain clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
unit. The nurse notes the sudden onset of premature ventricular contractions
(PVCs) on the monitor, checks the client's carotid pulse, and determines that the
PVCs are not perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI
(ANS- Ask the ED primary health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health
care provider to check the client. PVCs are a result of increased irritability of
ventricular cells. Peripheral pulses may be absent or diminished with the PVCs
themselves because the decreased stroke volume of the premature beats may in
turn decrease peripheral perfusion. Because other rhythms also cause widened
QRS complexes, it is essential that the nurse determine whether the premature
beats are resulting in perfusion of the extremities. This is done by palpating the
carotid, brachial, or femoral artery while observing the monitor for widened
complexes or by auscultating for apical heart sounds. In the situation of acute MI,
PVCs may be considered warning dysrhythmias, possibly heralding the onset of
ventricular tachycardia or ventricular fibrillation. Therefore, the nurse would not
tell the client that the PVCs are expected. Although the nurse will continue to
monitor the client and document the findings, these are not the most appropriate
actions of those provided.
NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the
procedure, the nurse checks the client's record and notes that the client routinely
takes an oral antihypertensive medication each morning. What action should the
nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT
(ANS- Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small
sip of water. Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the day after the
ECT are incorrect actions, because antihypertensives must be administered on
time; otherwise, the risk for rebound hypertension exists. The nurse would not
administer a medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider's office for a follow-up visit. On assessment, the
client tells the nurse that he is feeling depressed. Which response by the nurse is
therapeutic?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month."
(ANS- "Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this surgery
feels the same way for about a month" is a generalization that avoids the client's
feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor.
Which action should be the nurse's priority?
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR
(ANS- Contact the primary health care provider
Rationale: The priority action is for the nurse to contact the primary health care
provider. The FHR is assessed for at least 1 minute when the membranes rupture.
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul
or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis
and warrants notifying the primary health care provider. A large amount of vernix
in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid
may be seen in cases of postterm gestation or placental insufficiency. Checking the
fluid for protein is not associated with the data in the question. The nurse would
continue to monitor the client and the FHR and would document the findings.
A nurse has assisted a primary health care provider in inserting a central venous
access device into a client with a diagnosis of severe malnutrition who will be
receiving parenteral nutrition (PN). After insertion of the catheter what does the
nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate Infuse
normal saline solution through the catheter at a rate of 100 mL/hr to maintain
patency
(ANS- Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the
catheter has been placed but before it is used for infusions, its placement must be
checked with an x-ray. Hanging the prescribed bag of PN and starting the infusion
at the prescribed rate and infusing normal saline solution through the catheter at a
rate of 100 mL/hr to maintain patency are all incorrect because they could result in
the infusion of solution into a lung if a pneumothorax is present. Although the
nurse may obtain a blood glucose measurement to serve as a baseline, this action is
not the priority.
A rape victim being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the most appropriate response by
the nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
"Let's talk about the information that you need to determine your risk of
contracting HIV."
(ANS- "Let's talk about the information that you need to determine your risk of
contracting HIV."
Rationale: The most appropriate response by the nurse is the one that encourages
the client to talk about her condition. HIV is a concern of rape victims. Such
concern should always be addressed, and the victim should be given the
information needed to evaluate his or her risk. Pregnancy may occur as a result of
rape, and pregnancy prophylaxis can be offered in the emergency department or
during follow-up, once the results of a pregnancy test have been obtained.
However, stating, "You're more likely to get pregnant than to contract HIV" avoids
the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every
rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
A client is taking prescribed ibuprofen 200 mg orally four times daily, to relieve
joint pain resulting from rheumatoid arthritis. The client tells the nurse that the
medication is causing nausea and indigestion. What should the nurse tell the client?
"I will contact your primary health care provider."
"Stop taking the medication."
"Take the medication with food."
"Take the medication twice a day instead of four times a day."
(ANS- "Take the medication with food."
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects
include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion,
or epigastric pain). If gastrointestinal distress occurs, the client should be instructed
to take the medication with milk or food. The nurse would not instruct the client to
stop the medication or instruct the client to adjust the dosage of a prescribed
medication; these actions are not within the legal scope of the role of the nurse.
Contacting the primary health care provider is premature, because the client's
complaints are side effects that occasionally occur and can be relieved by taking
the medication with milk or food.
The night nurse is caring for a client who just had a craniotomy. The nurse is
monitoring the client's Jackson-Pratt drain that is being maintained on suction. The
nurse notes that a total of 200 mL of red drainage has drained from the
JacksonPratt (J-P) tube in the last 8 hours. What action should the nurse take?
Document the amount in the client's record.
Discontinue the Jackson-Pratt drain from suction.
Continue to monitor the amount and color of the drainage.
Notify the primary health care provider immediately of the amount of drainage.
(ANS- Notify the primary health care provider immediately of the amount of
drainage.
Rationale: The nurse must immediately notify the primary health care provider of
this excessive amount of drainage. The primary health care provider must also be
immediately notified of any saturated head dressings. The normal amount of
drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the
suction from the J-P drain is not an option and is not done. Also, just documenting
the amount in the client's record is not correct even though the nurse would
document that the primary health care provider was notified of the total drain
amount. Just continuing to monitor the amount of drainage is also not an option.
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a
client for the management of anxiety. The nurse prepares the medication as
prescribed. Over what period of time should the nurse administer this medication?
3 minutes
10 seconds
15 seconds
30 minutes
(ANS- 3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection,
each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten
seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.
A nurse, conducting an assessment of a client being seen in the clinic for
signs/symptoms of a sinus infection, asks the client about medications that he is
taking. The client tells the nurse that he is taking nefazodone hydrochloride. On the
basis of this information, the nurse determines that the client most likely has a
history of what problem?
Depression
Diabetes mellitus
Hyperthyroidism
Coronary artery disease
(ANS- Depression
Rationale: The client is most likely suffering from depression. Nefazodone
hydrochloride is an antidepressant used as maintenance therapy to prevent relapse
of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery
disease are not treated with this medication.
Phenelzine sulfate is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the
client to contact the primary health care provider immediately if he/she
experiences what sign/symptom?
Dry mouth
Restlessness
Feelings of depression
Neck stiffness or soreness
(ANS- Neck stiffness or soreness
Rationale: The client is taught to immediately contact the primary health care
provider if the client experiences any occipital headache radiating frontally and
neck stiffness or soreness, which could be the first sign of a hypertensive crisis.
Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant
and is used to treat depression. Hypertensive crisis, an adverse effect of this
medication, is characterized by hypertension, frontally radiating occipital
headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills,
clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and
constricting chest pain may also be present. Dry mouth and restlessness are
common side effects of the medication.
Risperidone is prescribed for a client hospitalized in the mental health unit for the
treatment of a psychotic disorder. Which finding in the client's medical record
would prompt the nurse to contact the prescribing primary health care provider
before administering the medication?
The client has a history of cataracts.
The client has a history of hypothyroidism.
The client takes a prescribed antihypertensive.
The client is allergic to acetylsalicylic acid (aspirin).
(ANS- The client takes a prescribed antihypertensive.
Rationale: Risperidone is an antipsychotic medication. Contraindications to the use
of risperidone include cardiac disorders, cerebrovascular disease, dehydration,
hypovolemia, and therapy with antihypertensive agents. Risperidone is used with
caution in clients with a history of seizures. History of cataracts, hypothyroidism,
or allergy to aspirin does not affect the administration of this medication.
A client who has been undergoing long-term therapy with an antipsychotic
medication is admitted to the inpatient mental health unit. Which finding does the
nurse, knowing that long-term use of an antipsychotic medication can cause tardive
dyskinesia, monitor in the client?
Fever
Diarrhea
Hypertension
Tongue protrusion
(ANS- Tongue protrusion
Rationale: The clinical manifestations include abnormal movements (dyskinesia)
and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face.
Tardive dyskinesia is a severe reaction associated with long-term use of
antipsychotic medications. In its most severe form, tardive dyskinesia involves the
fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is
discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive
dyskinesia.
A nurse is reviewing the record of a client scheduled for electroconvulsive therapy
(ECT). Which diagnosis, if noted on the client's record, would indicate a need to
contact the primary health care provider who is scheduled to perform the ECT?
Recent stroke
Hypothyroidism
History of glaucoma
Peripheral vascular disease
(ANS- Recent stroke
Rationale: Several conditions pose risks in the client scheduled for ECT. Among
them are recent myocardial infarction or stroke and cerebrovascular malformations
or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease
are not contraindications to this treatment.
The nurse is caring for a client who just returned to the surgical unit after having a
suprapubic prostatectomy. What type of medication does the nurse expect to be
ordered?
Phenothiazines
Antispasmodics
Antidyskinetics
Benzodiazepines
(ANS- Antispasmodics
Rationale: Antispasmodics are prescribed for bladder spasms related to a
suprapubic prostatectomy. This surgery involves removal of the prostate gland by
an abdominal incision with a bladder incision. Phenothiazines are a class of
antipsychotic medications. Antidyskinetics have an anticholinergic action and are
used to treat Parkinson's disease and some of the acute movement disorders that
may be caused by antipsychotic agents. Benzodiazepines are central nervous
system (CNS) depressants and can cause sedation and psychomotor slowing. They
can also intensify depression caused by other drugs. Benzodiazepines have some
potential for abuse and should be used with caution in clients known to abuse
alcohol or other psychoactive medications.
A nurse is preparing a poster for a health fair booth promoting primary prevention
of skin cancer. Which recommendations does the nurse include on the poster?
Select all that apply.
Seek medical advice if you find a skin lesion.
Use sunscreen with a low sun protection factor (SPF).
Avoid sun exposure before 10 a.m. and after 4 p.m.
Wear a hat, opaque clothing, and sunglasses when out in the sun.
Examine the body every 6 months for possibly cancerous or precancerous lesions.
(ANS- Seek medical advice if you find a skin lesion.
Wear a hat, opaque clothing, and sunglasses when out in the sun.
Wear a hat, opaque clothing, and sunglasses when out in the sun.
A nurse reviewing the medical record of a client with a diagnosis of infiltrating
ductal carcinoma of the breast notes documentation of the presence of peau
d'orange skin. On the basis of this notation, which finding would the nurse expect
to note on assessment of the client's breast?
(ANS- Rationale: Peau d'orange (French for "orange peel") is the term used to
describe skin dimpling, resembling the skin of an orange, at the location of a breast
mass. This change, along with increased vascularity, nipple retraction, or
ulceration, may indicate advanced disease. Erythema, or reddening, of the breast
indicates inflammation such as that resulting from cellulitis or a breast abscess.
Paget's disease is a rare type of breast cancer that is manifested as a red, scaly
nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the
nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy.
The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse
that her child is a member of the school soccer team and expresses concern about
her child's participation in sports. What does the nurse tell the mother after
providing information to the mother about diet, exercise, insulin, and blood
glucose control?
To always administer less insulin on the days of soccer games
That it is best not to encourage the child to participate in sports activities
That the child should eat a carbohydrate snack about a half-hour before each soccer
game
To administer additional insulin before a soccer game if the blood glucose level is
240 mg/dL (13.3 mmol/L) or higher and ketones are present.
(ANS- That the child should eat a carbohydrate snack about a half-hour before
each soccer game
Rationale: The child with diabetes mellitus who is active in sports requires
additional food intake in the form of a carbohydrate snack about a half-hour before
the anticipated activity. Additional food will need to be consumed, often as
frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If
the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and
ketones are present before planned exercise, the activity should be postponed until
the blood glucose has been controlled. Moderate to high ketone values should be
reported to the primary health care provider. There is no reason for the child to
avoid participating in sports.
A client diagnosed with chronic kidney disease who requires dialysis three times a
week for the rest of his life says to the nurse, "Why should I even bother to watch
what I eat and drink? It doesn't really matter what I do if I'm never going to get
better!" On the basis of the client's statement, the nurse determines that the client is
experiencing which problem?
Anxiety
Powerlessness
Ineffective coping
Disturbed body image
(ANS- Powerlessness
Rationale: Powerlessness is present when a client believes that he or she has no
control over the situation or that his or her actions will not affect an outcome in
any significant way. Anxiety is a vague uneasy feeling of apprehension. Some
factors in anxiety include a threat or perceived threat to physical or emotional
integrity or self-concept, changes in role function, and a threat to or change in
socioeconomic status. Ineffective coping is present when the client exhibits
impaired adaptive abilities or behaviors in meeting the demands or roles expected.
Disturbed body image is diagnosed when there is an alteration in the way the client
perceives his or her own body image.
A nurse is providing morning care to a client in end-stage kidney disease. The
client is reluctant to talk and shows little interest in participating in hygiene care.
Which statement by the nurse would be therapeutic?
"What are your feelings right now?"
"Why don't you feel like washing up?"
"You aren't talking today. Cat got your tongue?"
"You need to get yourself cleaned up. You have company coming today." (ANS-
"What are your feelings right now?"
Rationale: Asking, "What are your feelings right now?" encourages the client to
identify his or her emotions or feelings, which is a therapeutic communication
technique. In stating, "Why don't you feel like washing up?" the nurse is requesting
an explanation of feelings and behaviors for which the client may not know the
reason. Requesting an explanation is a nontherapeutic communication technique.
"You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The
statement "You need to get yourself cleaned up. You have company coming today"
is demanding, demeaning to the client, and nontherapeutic.
Empyema develops in a client with an infected pleural effusion, and the nurse
prepares the client for thoracentesis. The nurse is assisting the primary health care
provider with the procedure. What characteristics of the fluid removed during
thoracentesis should the nurse expect to note?
Clear and yellow
Thick and opaque
White and odorless
Clear, with a foul odor
(ANS- Thick and opaque
Rationale: Empyema is the accumulation of pus in the pleural space. Empyema
fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow,
white and odorless, and clear and foul-smelling are incorrect descriptions of the
fluid that occurs in this disorder.
An emergency department nurse is told that a client with carbon monoxide
poisoning resulting from a suicide attempt is being brought to the hospital by
emergency medical services. Which intervention will the nurse carry out as a
priority upon arrival of the client?
Administering 100% oxygen
Having a crisis counselor available
Instituting suicide precautions for the client
Obtaining blood for determination of the client's carboxyhemoglobin level
(ANS- Administering 100% oxygen
Rationale: With a client with carbon monoxide poisoning, the priority is to treat the
client with inhalation of 100% oxygen to shorten the half-life of carbon monoxide
to around an hour. Hyperbaric oxygen may be required to reduce the half-life to
minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the
poisoning occurred as a result of a suicide attempt, a crisis counselor should be
consulted, but this is not the priority. Suicide precautions should be instituted once
emergency interventions have been completed and the client has been admitted to
the hospital. The diagnosis is confirmed with a measurement of the
carboxyhemoglobin level in the client's blood. Obtaining a blood specimen to
measure the carboxyhemoglobin level is a priority; however, the nurse would
immediately administer 100% oxygen to the client.
A nurse is caring for a client with sarcoidosis. The client is upset because he has
missed work and worried about how he will care financially for his wife and three
small children. On the basis of the client's concern, which problem does the nurse
identify?
Anxiety
Powerlessness
Disruption of thought processes
Inability to maintain health
(ANS- Anxiety
Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related
factors include a threat or perceived threat to physical or emotional integrity or
self-concept, changes in function in one's role, and threats to or changes in
socioeconomic status. The client experiencing powerlessness expresses feelings of
having no control over a situation or outcome. Disruption of thought processes
involves disturbance of cognitive abilities or thought. Inability to maintain health is
being incapable of seeking out help needed to maintain health.
A nurse, performing an assessment of a client who has been admitted to the
hospital with suspected silicosis, is gathering both subjective and objective data.
Which question by the nurse would elicit data specific to the cause of this
disorder?
"Do you chew tobacco?"
"Do you smoke cigarettes?"
"Have you ever worked in a mine?"
"Are you frequently exposed to paint products?"
(ANS- "Have you ever worked in a mine?"
Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the
inhalation of free crystalline silica dust over a long period. Mining and quarrying
are each associated with a high incidence of silicosis. Hazardous exposure to silica
dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone
masonry, and the manufacture of glass, tile, and bricks. The finely ground silica
used in soaps, polishes, and filters also presents a risk. The assessment questions
noted in the other options are unrelated to the cause of silicosis.
A primary health care provider prescribes a dose of morphine sulfate 2.5 mg stat to
be administered intravenously to a client in pain. The nurse preparing the
medication notes that the label on the vial of morphine sulfate solution for
injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a
syringe for administration to the client? Type the answer in the space provided.
_____ mL (ANS- 0.625
A client undergoing therapy with carbidopa/levodopa calls the nurse at the clinic
and reports that his urine has become darker since he started taking the medication.
What should the nurse tell the client?
To call his primary health care provider
That he needs to drink more fluids
That this is an occasional side effect of the medication
That this may be a sign/symptom of developing toxicity of the medication
(ANS- That this is an occasional side effect of the medication
Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause darkening of
the urine or sweat. The client should be reassured that this is a harmless side effect
of the medication and that the medication's use should be continued. Although
fluid intake is important, telling the client that he needs to drink more fluid is
incorrect and unnecessary. Telling the client that the darkening of his urine may
signal developing medication toxicity is incorrect and might alarm the client
unnecessarily. There is no need for the client to call the primary health care
provider.
A client with myasthenia gravis is taking neostigmine bromide. What does the
nurse note that indicates the client is gaining a therapeutic effect from the
medication?
Bradycardia
Increased heart rate
Decreased blood pressure
Improved swallowing function
(ANS- Improved swallowing function
Rationale: Neostigmine bromide, a cholinergic medication that prevents the
destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would
monitor the client for a therapeutic response, which includes increased muscle
strength, an easing of fatigue, and improved chewing and swallowing function.
Bradycardia, increased heart rate, and decreased blood pressure are
signs/symptoms of an adverse reaction to the medication.
A nurse is assessing a client who has been taking amantadine hydrochloride for the
treatment of Parkinson's disease. Which finding from the history and physical
examination would cause the nurse to determine that the client may be
experiencing an adverse effect of the medication?
Insomnia
Rigidity and akinesia
Bilateral lung wheezes
Orthostatic hypotension (ANS- Bilateral lung wheezes
Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the
action of dopamine in the central nervous system (CNS). The medication is used to
treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of
the medication. Adverse effects include congestive heart failure (evidenced by
bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions,
and ventricular dysrhythmias.
A nurse who will be staffing a booth at a health fair is preparing pamphlets
containing information regarding the risk factors for osteoporosis. Which risk
factors does the nurse include in the pamphlet? Select all that apply.
Smoking
A high-calcium diet
High alcohol intake
White or Asian ethnicity
Participation in physical activities that promote flexibility and muscle strength
(ANS- Smoking
High alcohol intake
White or Asian ethnicity
Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in
decreased density and sometimes fractures. Risk factors include being 65 years or
older in women, 75 years or older in men, family history of the disorder, history of
fracture after age 50, white or Asian ethnicity, low body weight and slender build,
chronically low calcium intake, a history of smoking, high alcohol intake, and lack
of physical exercise or prolonged immobility.
A nurse is providing instruction to a client with osteoporosis regarding appropriate
foods to include in the diet. What one food item high in calcium does the nurse tell
the client to eat?
Corn
Cocoa
Peaches
Sardines
(ANS- Sardines
Rationale: Foods high in calcium include milk and milk products, dark-green leafy
vegetables, tofu and other soy products, sardines, and hard water. Osteoporosis is a
chronic metabolic disease in which bone loss results in decreased density and
sometimes fractures. Corn, cocoa, and peaches do not contain appreciable amounts
of calcium.
A nurse is providing information about home care to a client with acute gout.
Which measures does the nurse tell the client to take? Select all that apply.
Drinking 2 to 3 L of fluid each day
Applying heat packs to the affected joint
Resting and immobilizing the affected area
Consuming foods high in purines
Performing range-of-motion exercise to the affected joint three times a day
(ANS- Drinking 2 to 3 L of fluid each day
Resting and immobilizing the affected area
Rationale: Gout is a systemic disease in which urate crystals are deposited in the
joints and other tissues, resulting in inflammation. In acute gout, rest and
immobilization are recommended until the acute attack and inflammation have
subsided. Local application of cold may help relieve the pain. The application of
heat is avoided because it may worsen the inflammatory process. Dietary
instructions include reducing or eliminating alcohol intake and avoiding excessive
intake of foods containing purines (e.g., sweetbreads, yeast, heart, herring, herring
roe, sardines). The client is encouraged to drink 2 to 3 L of fluid per day to help
eliminate uric acid and to prevent the formation of renal calculi.
A nurse is gathering subjective and objective data from a client with suspected
rheumatoid arthritis (RA). Which early manifestations of RA would the nurse
expect to note? Select all that apply.
Fatigue
Anemia
Weight loss
Low-grade fever
Joint deformities
(ANS-
Fatigue
Low-grade fever
Rationale: Early manifestations of RA include fatigue, low-grade fever, weakness,
anorexia, and paresthesias. Rheumatoid arthritis is a chronic, progressive, systemic
and inflammatory autoimmune disease process that affects the synovial joints,
resulting in their destruction. Anemia, weight loss, and joint deformities are some
of the late manifestations.
A nurse is reviewing the medical record of a client with a suspected systemic lupus
erythematosus (SLE). Which manifestations of SLE would the nurse expect to find
noted in the client's medical record? Select all that apply.
Fever
Vasculitis
Weight gain
Increased energy
Abdominal pain
(ANS-
Fever
Vasculitis
Abdominal pain
Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory
disorder of the connective tissue that can cause the failure of major organs and
body systems. Manifestations include fever, fatigue, anorexia, weight loss,
vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly
pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge
of the nose. Other manifestations include nephritis, pericarditis, the Raynaud
phenomenon (discoloration of fingers and/or toes after exposure to changes in
temperature), pleural effusions, joint inflammation, and myositis.
A nurse is providing dietary instructions to a client who is taking tranylcypromine
sulfate. Which foods does the nurse tell the client to avoid while she is taking this
medication? Select all that apply.
Beer
Apples
Yogurt
Baked haddock
Pickled herring
Roasted fresh potatoes
(ANS-
Beer
Yogurt
Pickled herring
Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used
to treat depression. The client must follow a tyramine-restricted diet while taking
the medication to help prevent hypertensive crisis, a life-threatening effect of the
medication. Foods to be avoided include meats prepared with tenderizer, smoked
or pickled fish, beef or chicken liver, and dry sausages (e.g., salami, pepperoni,
bologna). In addition, figs, bananas, aged cheeses, yogurt and sour cream, beer, red
wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged,
pickled, fermented, or smoked foods must be avoided. Many over-the-counter
medications contain tyramine and must be avoided as well.
The blood serum level of imipramine is determined in a client who is being treated
for depression. The laboratory test indicates a concentration of 250 ng/mL. On the
basis of this result, what should the nurse do?
Contact the primary health care provider
Hold the next dose of imipramine
Document the laboratory result in the client's record
Have another blood sample drawn and ask the laboratory to recheck the
imipramine level
(ANS- Document the laboratory result in the client's record
Rationale: Imipramine is a tricyclic antidepressant that is often used to treat
depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so
the nurse would simply document the laboratory result in the client's record.
Asking the laboratory to recheck the level and withholding the next dose of the
imipramine and contacting the primary health care provider are unnecessary.
nurse provides instructions to a client who has been prescribed lithium carbonate
for the treatment of bipolar disorder. Which of these statements by the client
indicate a need for further instruction? Select all that apply.
"I need to avoid salt in my diet."
"It's fine to take any over-the-counter medication with the lithium."
"I need to come back to the clinic to have my lithium blood level checked."
"I should drink 2 to 3 quarts (1.9 to 2.8 litres) of liquid every day."
"Diarrhea and muscle weakness are to be expected, and if these occur I don't need
to be concerned."
(ANS- "I need to avoid salt in my diet."
"It's fine to take any over-the-counter medication with the lithium."
"Diarrhea and muscle weakness are to be expected, and if these occur I don't need
to be concerned."
Rationale: Lithium carbonate is a mood stabilizer used to treat manic-depressive
illness. Equilibrium of sodium and potassium must be maintained at the
intracellular membrane to maintain therapeutic effects. Lithium competes with
sodium in the cell. Therefore the client should maintain a normal salt intake and
drink 2 to 3 quarts (1.9 to 2.8 litres) of fluid each day. Many over-the-counter
medications contain sodium and would therefore affect the lithium concentration,
possibly pushing it out of the therapeutic range. For this reason, over-the-counter
medications must be avoided. The blood level of lithium should be tested every 3
or 4 days during the initial phase of therapy and every 1 to 2 months during
maintenance therapy. Vomiting, diarrhea, muscle weakness, tremors, drowsiness,
and ataxia are signs/symptoms of toxicity; if any of these problems occur, the
primary health care provider must be notified.
A client who is taking lithium carbonate complains of mild nausea and voiding in
large volumes. On assessment, the nurse notes that the client is also complaining of
mild thirst. On the basis of these findings, what would the nurse do?
Contact the primary health care provider
Document the findings
Institute seizure precautions
Have a blood specimen drawn immediately for serum lithium testing
(ANS- Document the findings
Rationale: Lithium carbonate is a mood stabilizer that is used to treat
manicdepressive illness. Side effects include polyuria, mild thirst, and mild nausea.
Therefore, the nurse should simply document the findings. Because the client's
complaints are side effects, not toxic effects, contacting the primary health care
provider, instituting seizure precautions, and having a specimen drawn
immediately for a serum lithium determination are all unnecessary. Vomiting,
diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of
toxicity and if these occur the primary health care provider needs to be notified.
A client with agoraphobia will undergo systematic desensitization through
graduated exposure. In explaining the treatment to the client, what does the nurse
tell the client this technique involves?
Having the client perform a healthy coping behavior
Having the client perform a ritualistic or compulsive behavior
Providing a high degree of exposure of the client to the stimulus that the client
finds undesirable
Gradually introducing the client to a phobic object or situation in a predetermined
sequence of least to most frightening
(ANS- Gradually introducing the client to a phobic object or situation in a
predetermined sequence of least to most frightening
Rationale: The technique of systematic desensitization involves gradually
introducing the client to a phobic object or situation in a predetermined sequence
of least to most frightening with the goal of defusing the phobia. Having the client
perform a healthy coping behavior is the description of modeling. Performing
ritualistic or compulsive behaviors is a behavior characteristic of clients with
obsessive-compulsive disorder. Having the client perform a ritualistic or
compulsive behavior may not be therapeutic; additionally, it is not associated with
systematic desensitization. Providing a high degree of exposure to a stimulus that
the client finds undesirable is the technique known as flooding.
The nurse is caring for a client who has just undergone
esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really
thirsty — may I have something to drink?" Before giving the client a drink, what
would the nurse do?
Check the client's vital signs
Check for the presence of a gag reflex
Assess the client for the presence of bowel sounds
Ask the client to gargle with a warm saline solution
(ANS- Check for the presence of a gag reflex
Rationale: After an EGD, the nurse places the highest priority on assessing the
client for the return of the gag reflex. In preparation for EGD, the client's throat is
usually sprayed with an anesthetic to dampen the gag reflex and permit the
introduction of the endoscope used to visualize the gastrointestinal structures. No
food or oral fluids are given to the client until the gag reflex is fully intact.Vital
signs are checked frequently, but this action is not associated with giving the client
oral fluids. The client may be asked to use throat lozenges or a saline gargle to
relieve a sore throat after the test, but neither action is related to giving the client
oral fluids; additionally, neither action would be taken until the gag reflex had been
detected again. Bowel sounds are not affected by this test. [Show Less]