Adult Care 3 Exam 3 ATI

Question 1

A nurse is assessing a client who is African American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Palms of the hands
Hard palate
Conjunctiva
Back of the neck

Answer 1

Palms of the Hands
INCORRECT
The nurse should inspect the palms of a client who is Caucasian for jaundice. However, evidence-based practice indicates calloused palms may appear yellow in African-American clients. Therefore, there is another area the nurse should assess.

Hard Palate
CORRECT
According to evidence-based practice, inspecting the client’s oral mucous membrane and hard palate is the most reliable method to determine jaundice for a client who is African-American.

Conjunctiva
INCORRECT (My Answer)
The nurse should inspect the conjunctiva of a client who is Caucasian as mucous membranes develop a yellow tinge. However, evidence-based practice indicates that clients who are African-American do not develop this manifestation with jaundice. Therefore, there is another area the nurse should assess.

Skin Color
INCORRECT
The nurse should inspect the skin color of a Caucasian client who has jaundice as the skin develops a yellow tone. However, evidence-based practice indicates clients who are African-American do not develop this manifestation with jaundice. Therefore, there is another area the nurse should assess.

Question 2

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?

Place the client in a supine position postoperatively.
Encourage ambulation once fully awake.
Offer the client ice cream postoperatively.
Instruct the client not to lift over 4.5 kg (10 lb).

Answer 2

Place the client in a supine position postoperatively

INCORRECT
The nurse should place the client in Semi-Fowler’s position to promote lung expansion. If needed, the nurse can use the lateral or Sims’ position for a client who is unconscious to prevent aspiration.

Encourage ambulation once fully awake.

CORRECT
The nurse should encourage ambulation once the client is fully awake to promote absorption of the carbon dioxide used during the laparoscopy. This minimizes the client’s discomfort. The nurse should check the client for nausea before ambulating and administer an antiemetic medication if necessary.

Offer the client ice cream postoperatively

INCORRECT
The nurse should offer foods low in fat to prevent nausea and vomiting. The nurse should also offer foods that are high in carbohydrates and protein to provide adequate nutrition.

Instruct the client not to lift over 45 kg (10 lb)

INCORRECT (My Answer)
The nurse should instruct the client not to lift more than 2.3 kg (5 lb) following surgery.

Question 3

A nurse is assessing a client who has multiple sclerosis. Which of the following assessment findings should the nurse anticipate? (Select all that apply.)

Paresthesia
Nausea and vomiting
Dysphagia
Spasticity
Vertigo

Answer 3

A,C,D,E
Clients who have multiple sclerosis have multiple manifestations that include paresthesia, dysphagia, spasticity, and vertigo.

Question 4

A nurse is caring for a client who reports to the clinic for laboratory tests. The client has an acute kidney injury caused by acute tubular necrosis and asks why their glomerular filtration rate keeps decreasing. Which of the following pathophysiological changes occurring in the kidney should the nurse explain as the cause of the decrease?

The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys.
The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys.
The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down.
The glomerular filtration rate decreases because there is injury to the renal tubular cells.

Answer 4

The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys.
INCORRECT
This pathophysiological change occurs in prerenal acute kidney injury.

The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys.
INCORRECT
This pathophysiological change occurs in chronic kidney disease.

The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down.
INCORRECT
This pathophysiological change occurs in post-renal acute kidney injury.

The glomerular filtration rate decreases because there is injury to the renal tubular cells.
CORRECT
This is correct because this pathophysiological change occurs in acute tubular necrosis.

Question 5

A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

The pancreas’s location increases the risk that cancer will spread into nearby structures and blood vessels.
Pancreatic cancers are classified as either endocrine pancreatic cancer or exocrine pancreatic cancer.
Pancreatic cancer typically develops from a polyp.
Pancreatic cancer is distinguished based on the layers of the pancreas.

Answer 5

The pancreas’s location increases the risk that cancer will spread into nearby structures and blood vessels.
CORRECT
The nurse should include this information because pancreatic cancer’s ability to spread easily to nearby structures will directly impact the client’s treatment and prognosis.

Pancreatic cancers are classified as either endocrine pancreatic cancer or exocrine pancreatic cancer.
INCORRECT
The nurse should not include this information because pancreatic cancers are distinguished by their location on the pancreas, not by whether they are endocrine or exocrine.

Pancreatic cancer typically develops from a polyp.
INCORRECT
The nurse should not include this information because colon cancer typically begins from a polyp on the innermost surface of the colon or rectum, not pancreatic cancer.

Pancreatic cancer is distinguished based on the layers of the pancreas.
INCORRECT
The nurse should not include this information because pancreatic cancer is distinguished by its location (endocrine vs. exocrine) rather than by the layers of the pancreas.

Question 6

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Bradypnea.
Pruritus
Bone pain
Slurred speech
Hypotension

Answer 6

A, B, D

Slurred speech is correct. Slurred speech is an expected finding of ESKD.

Bone pain is correct. Bone pain is an expected finding of ESKD.

Bradypnea is incorrect. Tachypnea, rather than bradypnea, is an expected finding of ESKD.

Pruritus is correct. Pruritus is an expected finding of ESKD.

Hypotension is incorrect. Hypertension, rather than hypotension, is an expected finding of EKRD.

Question 7

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Include foods high in starch and proteins.
Include foods high in fiber.
Avoid foods high in fat.
Avoid foods high in sodium.

Answer 7

Include foods high in starch and proteins.
Foods high in starch and proteins do not affect the episodes of biliary colic.
Include foods high in fiber.
A high-fiber diet does not affect the episodes of biliary colic.
Avoid foods high in fat.
CORRECT
The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods.
Avoid foods high in sodium.
A low-sodium diet does not affect the episodes of biliary colic.

Question 8

A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client’s manifestations?

Hypovolemia
Hypervolemia
Hyperkalemia
Hyponatremia

Answer 8

Hypovolemia
INCORRECT
A client who has ESKD experiences severe disruptions in fluid and electrolyte balance. During the end stages, the kidney is severely limited in its ability to excrete fluids, resulting in fluid overload, rather than dehydration.
Hypervolemia
CORRECT
A client who has ESKD experiences excess fluid volume. The increase in circulating fluid causes hypertension which, along with the anemia that occurs in ESKD, ultimately causes heart failure. The client’s manifestations of dyspnea, crackles, and edema indicate the client is experiencing heart failure.
Hyperkalemia
A client who has ESKD will have hyperkalemia due to protein catabolism and a decreased ability to excrete excess potassium. However, the nurse should expect manifestations of hyperkalemia to include changes in cardiac rate and rhythm, weakness and paresthesia, and an increase in intestinal motility.
Hyponatremia
A client who has ESKD will have hypernatremia due to an inability of the kidneys to excrete sodium. The nurse should expect manifestations of hypernatremia to include changes in the level of consciousness, muscle weakness, and decreased or absent deep-tendon reflexes.

Question 9

A nurse is monitoring a client who a has acute kidney injury. Which of the following laboratory findings should the nurse expect?

Hypokalemia
Metabolic alkalosis
Hypercalcemia
Elevated BUN

Answer 9

Elevated BUN
CORRECT
Client who are in acute kidney injury will have an elevated BUN as damage to the kidneys leads to a build-up of nitrogenous wastes in the blood.

Question 10

A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
Auscultate the client’s lungs.
Assist the client to a side-lying position.
Provide oral hygiene.
Withhold oral fluids and food.

Answer 10

Auscultate the client’s lungs.
Monitoring respiratory status is appropriate; however, another action is the priority.
Assist the client to a side-lying position.
Encouraging a side-lying position with knees flexed is appropriate; however, another action is the priority.
Provide oral hygiene.
Providing oral hygiene is appropriate and should be done frequently; however, another action is the priority.
Withhold oral fluids and food.
CORRECT
To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client’s pain has been treated.

Question 11

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client’s plan of care?

Cleanse the perineum from back to front.
Obtain a prescription for an indwelling urinary catheter.
Encourage fluid intake at and between meals.
Offer the client the bedpan every 2 hr.

Answer 11

Cleanse the perineum from back to front.
The perineum should be cleansed from front to back to limit the spread of bacteria from the perianal region to the urethra in female clients.
Obtain a prescription for an indwelling urinary catheter.
Indwelling catheters are associated with a greatly increased risk for UTI and should be avoided whenever possible in a client who is at risk. Intermittent catheterization to empty the bladder of residual urine is more effective.
Encourage fluid intake at and between meals.
CORRECT
Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.
Offer the client the bedpan every 2 hr.
The client will be unable to completely empty her bladder by herself.

Question 12

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
Initiate a low-residue diet.
Pantoprazole 80 mg IV bolus twice daily
Ambulate twice daily.
Pancrelipase 500 units/kg PO three times daily with meals

Answer 12

Initiate a low-residue diet.
One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate the provider will prescribe withholding of foods and fluids. This serves to manage the client’s pain by limiting gastrointestinal activity and stimulation of the pancreas.
Pantoprazole 80 mg IV bolus twice daily
CORRECT
The nurse should anticipate a provider’s prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.
Ambulate twice daily.
The nurse should anticipate a provider prescription for bed rest during the acute stage of pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes.
Pancrelipase 500 units/kg PO three times daily with meals
The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute pancreatitis.

Question 13

A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock?
(Select All that Apply.)

Calcium level 7.0 mg/dL
Respirations 12/min
Blood pressure 184/88 mm Hg
Temperature 36.3° C (97.4° F)
Heart rate 54/min

Answer 13

B,D,E
Clients who have spinal cord injuries can develop neurogenic shock, which results from a reduction in sympathetic tone in the blood vessels and leads to significant hypotension, bradycardia, and hypothermia, due to an imbalance in the parasympathetic system.

A blood pressure of 184/88 mm Hg is not a finding in neurogenic shock. Blood pressure with neurogenic shock will be low.

Clients who have spinal cord injuries can develop neurogenic shock, which results from a reduction in sympathetic tone in the blood vessels and leads to significant hypotension, bradycardia, and hypothermia, due to an imbalance in the parasympathetic system.

A respiratory rate of 12/min is within normal limits and is not a finding of neurogenic shock.

A calcium level of 7.0 mg/dL is low, but it is not a finding in neurogenic shock. Normal range for calcium is 9.0 to 10.5 mg/dL.

Question 14

A nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, “Why can’t I just take the antacid magaldrate my husband has at home?” The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following?
Serum phosphorus levels
Serum potassium levels
Serum magnesium levels
Serum calcium levels

Answer 14

Serum phosphorus levels
CORRECT
Aluminum-based formulas are also a phosphate binder, helping to lower serum phosphorus levels in clients who have CKD.
Serum potassium levels
Neither aluminum-based nor magnesium-based antacids have an effect on potassium levels.
Serum magnesium levels
Aluminum-based antacids have no effect on magnesium levels, but magnesium-based antacids may elevate magnesium levels.
Serum calcium levels
Aluminum-based formulas elevate serum calcium levels.

Question 15

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following set of values should the nurse expect?

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg

Answer 15

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
CORRECT
The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.
pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
These values indicate respiratory acidosis, which is associated with respiratory disorders, such as pulmonary edema and pneumonia.
pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
These values indicate respiratory alkalosis, which is associated with hyperventilation.
pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
These values indicate metabolic alkalosis, which is associated with severe emesis or gastric suctioning.

Question 16

A nurse in the emergency department is monitoring a client who has a cervical spinal injury from a fall. The nurse should monitor the client for which of the following complications?
(Select All that Apply.)

Hyperthermia
Absence of bowel sounds
Polyuria
Weakened gag reflex
Hypotension

Answer 16

A, D, E

Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client’s SBP at 90 mm Hg or above to adequately perfuse the spinal cord.

Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles.

Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input.

Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

Question 17

A nurse is teaching the family of a a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

“Turn the screws on the device once each day.”
“The purpose of this device is to immobilize the cervical spine.”
“Apply talcum powder under the vest to limit friction.”
“The purpose of this device is to allow for neck movement during the healing process.”

Answer 17

“The purpose of this device is to immobilize the cervical spine.”
CORRECT
A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

Question 18

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client’s plan of care?

Ability to achieve independent transfer from bed to wheelchair
Independent control of bowel and bladder function
Use of a wheelchair with a chin or mouth stick
Ability to self-feed with the use of adaptive equipment

Answer 18

Ability to self-feed with the use of adaptive equipment
CORRECT
A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment.

Ability to achieve independent transfer from bed to wheelchair
INCORRECT
A client who has a transection at the level of C6 or lower should be able to transfer from a bed to a chair independently.
Independent control of bowel and bladder function

Independent control of bowel and bladder function
INCORRECT
A client who has a transection in the sacral area might have full or partial bowel and bladder control; a client who has a cervical transection will not.
Use of a wheelchair with a chin or mouth stick

Use of a wheelchair with a chin or mouth stick.
INCORRECT
A client who has a transection at the level of C5 can use an electric or modified manual wheelchair.

Question 18

S/S of progressive multifocal leukoencephalopathy (PML)

Answer 18

When using the evidence-based practice priority framework, the nurse should determine that the priority hypothesis is the client developing progressive multifocal leukoencephalopathy (PML) as evidenced by the client’s loss of coordination, ataxia, increasing weakness, difficult speech, confusion, and visual changes. The client had started Natalizumab which is known to potentially cause PML.

Question 19

A nurse is teaching a client who has multiple sclerosis about factors that can worsen their manifestations. Which of the following factors should the nurse include in the teaching?

High altitude travel
Flying
Sunbathing
Working in an office

Answer 19

Sunbathing
CORRECT
Clients who have multiple sclerosis often see a temporary worsening of symptoms in hot or humid weather, when sunbathing, with hot showers or baths, with exercise, or when they run a fever. The elevation in temperature impairs the ability of the demyelinated nerve to transmit electrical impulses.

Question 20

A nurse is caring for a client who has multiple sclerosis. Which of the following factors should the nurse anticipate have been identified as contributing to the development of multiple sclerosis?

(Select All that Apply.)

Genetics
Environmental factors
Upper respiratory infections
Autoimmune factors
Urinary tract infections

Answer 20

A,B,D

There are three kinds of factors that have been linked to the development of multiple sclerosis: genetic, environmental, and autoimmune factors.

Question 21

A nurse is caring for a client who is being evaluated for multiple sclerosis. Which of the following tests should the nurse anticipate the provider will order to assist with diagnosis?

Troponin level
Brain natriuretic peptide
Myelogram
Lumbar puncture

Answer 21

Lumbar puncture
CORRECT
Providers can use lumbar puncture to assist with diagnosis of multiple sclerosis. A cerebrospinal fluid sample is collected by lumbar puncture and examined for elevated protein levels and for a group of proteins called oligoclonal bands.

Question 22

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm HG and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Administer a nitrate antihypertensive.
Assess the client for bladder distention.
Place the client in a high-Fowler’s position.
Obtain the client’s heart rate.

Answer 22

Place the client in a high-Fowler’s position.
CORRECT
The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse’s initial action should be to place the client in a high-Fowler’s position to assist in providing immediate reduction in blood pressure and intracranial pressure.

Question 23

Assessment findings for MI and GERD:
Eructation, hoarseness, Nausea, Indigestion, and Dyspnea

Answer 23

MI: Indigestion, nausea, dyspnea

GERD: Indigestion, nausea, hoarseness, eructation

Question 24

A nurse us providing teaching about potential complications to a client who has a spinal cord injury. Which of the following should the nurse include in the teaching as a common complication of spinal cord injuries?

(Select All that Apply.)

Temperature sensitivity
Contractures
Sexual dysfunction
Disc degeneration
Urinary tract infections

Answer 24

B, C, E
The nurse should recognize common complications of spinal cord injuries include spasticity, urinary tract infections, chronic pain, sexual dysfunction, bowel and bladder dysfunction, sleep problems, and contractures.

Question 25

A nurse is presenting discharge instructions to a client who has MS. The client reports symptoms of diplopia, dysmetria, and sensory changes. Which of the following nursing statements are appropriate?

“Wear an eye patch on the right eye at all times.”
“Plan to relax in a hot tub spa each day.”
“Engage in a vigorous exercise program.”
“Implement a schedule to include periods of rest.”

Answer 25

“Implement a schedule to include periods of rest.”
CORRECT
The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

Question 26

A nurse is preparing discharge instructions for a client who has been treated for acute pancreatitis. Which of the following statements is important to include in the information?

Stop exercising.
Cease from smoking and consuming alcohol.
Practice good dental hygiene.
Avoid wearing tight-fitting clothing.

Answer 26

Stop exercising.
INCORRECT
Avoiding exercise is not necessary with a previous episode of pancreatitis.

Cease from smoking and consuming alcohol.
CORRECT
My Answer
The nurse will want to educate the client on avoidance of alcohol and smoking cessation.

Practice good dental hygiene.
INCORRECT
It is always important to practice good dental hygiene, but this is not an important educational statement to relay for clients with a previous episode of pancreatitis.

Avoid wearing tight-fitting clothing.
INCORRECT
Avoiding tight-fitting clothes is not necessary with a previous episode of pancreatitis.

Question 27

A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? SATA

“To achieve a bowel movement, daily digital stimulation will need to be done.”
“Do not drink fluids excessively as this may cause diarrhea.”
“It will be necessary to take a stool softener to keep you from becoming constipated.”
“Suprapubic catheterization might have to be done if you are unable to catheterize yourself.”
“You will need to learn how to do self-intermittent catheterization to drain your bladder.”

Answer 27

A,C,D,E
Stool softeners should be administered routinely with stimulants and enemas as needed to keep bowel movements regular and prevent constipation.

Spinal cord injury clients should be encouraged to drink fluids. This will not cause the client to have diarrhea.

Clients should be taught clean intermittent self-catheterization to prevent bladder retention.

Clients who have a complete spinal cord injury require rectal stimulation daily to achieve and maintain bowel regularity.

Suprapubic catheters are typically reserved for clients who are unable to perform self-catheterization.

Question 28

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
The client states having a severe headache.
The client’s bladder becomes distended.
The client’s blood pressure becomes elevated.
The client states having nasal congestion.

Answer 28

The client’s bladder becomes distended.
Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

The client states having a severe headache.
INCORRECT
Although a client who has a T-4 spinal cord injury may complain of a severe headache, the nurse should recognize this as one of the manifestations of autonomic dysreflexia, rather than a causative agent. Emergency care of the client who experiences autonomic dysreflexia is to place the client into a sitting position and assess and treat the underlying cause.
The client’s blood pressure becomes elevated.
Severe hypertension should indicate to the nurse that the client is experiencing autonomic dysreflexia. Extremely elevated blood pressure is the most serious manifestation seen in autonomic dysreflexia as it may result in the client experiencing a stroke, but it is not a triggering factor.
The client states having nasal congestion.
A client who has a spinal injury above the level of T-6 is at risk for the development of autonomic dysreflexia. If the client develops nasal congestion, they may be experiencing the manifestations of autonomic dysreflexia. The nurse should investigate further by assessing the client’s blood pressure and taking emergency actions to treat the disorder.

Question 29

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client’s urine to appear which of the following colors?

Pale yellow
Greenish-brown
Red
Dark and foamy

Answer 29

Dark and foamy
The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

Question 30

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? SATA

Green Beans
Tomatoes
Bananas
Asparagus
Raisins

Answer 30

Tomatoes, banana, and raisins

Question 31

S/s of spinal cord injury, MS, and degenerative disc disease

Muscle strength, voiding concern, BP trends, and CT scan results

Answer 31

The findings of spinal cord injury include voiding concern, muscle strength, and blood pressure trends.

Voiding concerns such as bladder flaccidity or spasticity and muscle strength (generalized weakness and spasticity) are findings of multiple sclerosis.

CT scan results of ossifications within the right hip and generalized weakness related to joint stiffness are findings of degenerative disc disease.