Exam 2 Prep U

Question 1

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

Answer 1

dehydrate the brain and reduce cerebral edema.
Explanation:
Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

Question 2

To meet the sensory needs of a client with viral meningitis, the nurse should:

Answer 2

minimize exposure to bright lights and noise.
Explanation:
Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

Question 3

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client’s posture as

Answer 3

decerebrate.
Explanation:
Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client’s head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

Question 4

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

Answer 4

“You must avoid coughing, sneezing, and blowing your nose.”
Explanation:
After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

Question 5

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Answer 5

Gingival hyperplasia
Explanation:
Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

Question 6

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Answer 6

Osteoporosis
Explanation:
Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

Question 7

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Answer 7

Generalized
Explanation:
A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

Question 8

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Answer 8

Compliance with the prescribed medication regimen
Explanation:
The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client’s stress level, and weight change don’t contribute to this condition.

Question 9

Which positions is used to help reduce intracranial pressure (ICP)?

Answer 9

Avoiding flexion of the neck with use of a cervical collar
Explanation:
Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Question 10

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

Answer 10

Glasgow Coma Scale

Explanation:
An altered level of consciousness (LOC) is present when the client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.

Question 11

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Answer 11

Apply warm or cool cloths to the forehead or back of the neck.
Explanation:
Warmth promotes vasodilation; cool stimuli reduce blood flow.

Question 12

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Answer 12

Administer stool softeners.
Explanation:
Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

Question 13

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Answer 13

Lamictal
Explanation:
Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

Question 14

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Answer 14

Lethargy and stupor
Explanation:
As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

Question 15

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Answer 15

Brain tumor
Explanation:
The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.

Question 16

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Answer 16

Seizure was 1 minute in duration including tonic-clonic activity.
Explanation:
Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

Question 17

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

Answer 17

shivering in hypothermia can increase ICP.
Explanation:
Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

Question 18

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

Answer 18

High in protein and low in carbohydrate
Explanation:
A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).

Question 19

A nurse assesses the patient’s LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

Answer 19

3
Explanation:
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient’s responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

Question 20

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Answer 20

Temperature increase from 98.0°F to 99.6°F
Explanation:
Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client’s temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

Question 21

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Answer 21

Traction with weights and pulleys
Explanation:
Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client’s position without altering the alignment of the spine.

Question 22

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

Answer 22

An intracerebral hematoma
Explanation:
Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

Question 23

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Answer 23

LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient’s responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

Question 24

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

Answer 24

Change in level of consciousness (LOC)
Explanation:
The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.

Question 25

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

Answer 25

T6 Explanation: Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

Question 26

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

Answer 26

raccoon's eyes and Battle sign. Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

Question 27

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?

Answer 27

Autonomic dysreflexia Explanation: Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.

Question 28

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

Answer 28

It allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.

Question 29

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

Answer 29

vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

Question 30

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

Answer 30

concussion Explanation: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.

Question 31

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

Answer 31

30-degree head elevation Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

Question 32

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is

Answer 32

Motor vehicle crashes Explanation: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

Question 33

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Answer 33

Monitoring is needed as rapid neurologic deterioration may occur. Explanation: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

Question 34

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?

Answer 34

An area of bruising over the mastoid bone Explanation: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.

Question 35

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Answer 35

Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

Question 36

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Answer 36

Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

Question 37

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Answer 37

Lactated Ringer's Explanation: With increasing ICP, isotonic normal saline, lactated Ringer’s, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

Question 38

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

Answer 38

diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

Question 39

Which is a late sign of increased intracranial pressure (ICP)?

Answer 39

Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

Question 40

While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

Answer 40

Cluster Explanation: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.

Question 41

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?

Answer 41

Airway clearance Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

Question 42

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Answer 42

Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

Question 43

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

Answer 43

Glasgow Coma Scale Explanation: An altered level of consciousness (LOC) is present when the client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.

Question 44

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

Answer 44

chewing Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing.

Question 45

A nurse is assessing a patient’s urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

Answer 45

More than 200 mL/h Explanation: For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).

Question 46

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

Answer 46

Urinary tract infection Explanation: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.

Question 47

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Answer 47

Aspiration of a brain abscess Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

Question 48

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Answer 48

Administer corticosteroids as ordered. Explanation: Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

Question 49

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Answer 49

Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.

Question 50

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

Answer 50

The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

Question 51

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

Answer 51

Verapamil (Calan) Explanation: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.

Question 52

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Answer 52

Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

Question 53

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Answer 53

Drooping eyelids Explanation: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.

Question 54

Cerebral edema peaks at which time point after intracranial surgery?

Answer 54

24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.

Question 55

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?

Answer 55

Excessive urine output and decreased urine osmolality Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.

Question 56

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

Answer 56

“My children are at greater risk to develop this disease.” Explanation: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.

Question 57

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

Answer 57

"There is a strong familial tendency." Explanation: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.

Question 58

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Answer 58

Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days’ duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.

Question 59

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Answer 59

Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

Question 60

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:

Answer 60

52 mm Hg. Explanation: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg

Question 61

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition?

Answer 61

Hypocortisolism Explanation: Although steroids should be given during surgery to prevent hypocortisolism, the nurse should assess the client for it. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Signs of hypocortisolism include vomiting, increased weakness, dehydration, and hypotension. After the corticotropin-secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance and hypoglycemia shouldn't occur in this situation.

Question 62

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

Answer 62

Diplopia. Explanation: The initial manifestation of MG usually involves the ocular muscles. Diplopia (double vision) and ptosis (drooping of the eyelids) are common. The majority of patients also experience weakness of the muscles of the face and throat, generalized weakness, and weakness of the facial muscles.

Question 63

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Answer 63

Increased ICP is 12 mm Hg. Explanation: A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.

Question 64

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Answer 64

Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

Question 65

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Answer 65

Irrigates the wound to remove debris Explanation: Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

Question 66

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Answer 66

Alteration in level of consciousness (LOC) Explanation: The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.

Question 67

When caring for a client who is post–intracranial surgery what is the most important parameter to monitor?

Answer 67

Body temperature Explanation: It is important to monitor the client’s body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

Question 68

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Answer 68

Maintain cerebral perfusion pressure from 50 to 70 mm Hg Explanation: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client’s head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Question 69

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

Answer 69

coma. Explanation: The GCS is a tool for assessing a client’s response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed “least” responsive.

Question 70

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Answer 70

Insertion of a nasogastric (NG) tube Explanation: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

Question 71

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Answer 71

Basilar skull fracture Explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

Question 72

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Answer 72

Severe TBI. Explanation: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

Question 73

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Answer 73

Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

Question 74

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Answer 74

Absence of reflexes along with flaccid extremities Explanation: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

Question 75

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Answer 75

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

Question 76

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.

Answer 76

The three cardinal signs of brain death on clinical examination are coma, the absence of brain stem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brain stem auditory evoked potential, are often used to confirm brain death.

Question 77

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Answer 77

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Explanation: Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

Question 78

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:

Answer 78

famotidine (Pepcid). Explanation: Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

Question 79

The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?

Answer 79

The client will experience grief in an individualized manner. Explanation: Loss of limb is a profoundly emotional experience, which the client will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the client's grief. The client may or may not benefit from psychotherapy.

Question 80

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Answer 80

Edrophonium (Tensilon) Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

Question 81

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Answer 81

Antibodies are removed from the plasma. Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.

Question 82

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

Answer 82

2.5 g/mL Explanation: Serum albumin is a sensitive indicator of protein deficiency. Levels below 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.

Question 83

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Answer 83

Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

Question 84

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Answer 84

Within 24 hours after exposure Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

Question 85

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Answer 85

Alternatively patch one eye every 2 hours. Explanation: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

Question 86

During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client?

Answer 86

Prevention of joint contractures Explanation: A critical intervention during the acute phase of a stroke is to prevent joint contractures to avoid complications later in the client's rehabilitation. Joint contractures are prevented through correct body positioning and by putting affected extremities through a full range of motion four or five times a day. Promoting critical thinking ability and using adaptive equipment are not priorities during the acute phase. Creating a positive environment is helpful in motivating the client, but this is not as high a priority as the prevention of joint contractures.

Question 87

The most common cause of cholinergic crisis includes which of the following?

Answer 87

Overmedication Explanation: A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.

Question 88

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Answer 88

Pyridostigmine bromide (Mestinon) Explanation: Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.

Question 89

The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS?

Answer 89

Oligoclonal bands Explanation: Electrophoresis of the CSF, a technique for electrically separating and identifying proteins, demonstrates abnormal immunoglobulin G bands, described as oligoclonal bands. An elevated acetylcholine receptor antibody titer and IV administration of edrophonium are diagnostic of Myasthenia Gravis. Episodes of muscle fasciculations are characteristic of ALS.

Question 90

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Answer 90

Ensure atropine is readily available. Explanation: Atropine should be ready before administration of edrophonium chloride so it is available if needed to control the side effects of the medication. Assessing facial weakness and documenting the results occur after the administration of edrophonium chloride; therefore, they are not the priority interventions.

Question 91

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Answer 91

Client does not reach the toilet before experiencing voiding. Explanation: Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

Question 92

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Answer 92

Cerebellar abscess Explanation: Indicators of a cerebellar abscess include occipital headache, ataxia, and nystagmus.

Question 93

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?

Answer 93

Increase carbohydrates and limit protein intake. Explanation: Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.

Question 94

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Answer 94

Risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

Question 95

A client has undergone diagnostic testing that involved the insertion of a lighted tube with a telescopic lens. The nurse identifies this test as which of the following?

Answer 95

Cystoscopy Explanation: Cystoscopy is the visual examination of the inside of the bladder using an instrument called a cystoscope, a lighted tube with a telescopic lens. Renal angiography involves the passage of a catheter up the femoral artery into the aorta to the level of the renal vessels. Intravenous pyelography or excretory urography is a radiologic study that involves the use of a contrast medium to evaluate the kidneys' ability to excrete it.

Question 96

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?

Answer 96

Azotemia Explanation: The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood.

Question 97

Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?

Answer 97

Angiography Explanation: Angiography provides the details of the arterial supply to the kidneys, specifically the number and location of renal arteries. Radiography shows the size and position of the kidneys, ureters, and bladder. A CT scan is useful in identifying calculi, congenital abnormalities, obstruction, infections, and polycystic diseases. Cystoscopy is used for providing a visual examination of the internal bladder.

Question 98

A nurse is reviewing the laboratory test results of a client with renal disease. Which of the following would the nurse expect to find?

Answer 98

Increased serum creatinine Explanation: In clients with renal disease, the serum creatinine level would be increased. The BUN also would be increased, serum albumin would be decreased, and potassium would likely be increased.

Question 99

While reviewing a client’s chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question?

Answer 99

“Do you urinate while sleeping?” Explanation: Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client’s voiding pattern.

Question 100

The nurse is able to identify which condition as uremia?

Answer 100

An excess of urea in the blood Explanation: Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.

Question 101

Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?

Answer 101

Glomerulonephritis Explanation: Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

Question 102

What is a hallmark of the diagnosis of nephrotic syndrome?

Answer 102

Proteinuria Explanation: Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.

Question 103

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?

Answer 103

Administration of sodium polystyrene sulfonate [Kayexalate]) Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

Question 104

A client has been diagnosed with acute glomerulonephritis. This condition causes:

Answer 104

proteinuria. Explanation: The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Pyuria is pus in the urine. Polyuria is an increased volume of urine voided.

Question 105

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?

Answer 105

Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Explanation: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.

Question 106

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid–base imbalance is associated with this disorder?

Answer 106

pH 7.20, PaCO2 36, HCO3 14– Explanation: Metabolic acidosis occurs in end-stage kidney disease (ESKD) because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3–) and to reabsorb sodium bicarbonate (HCO3–). There is also decreased excretion of phosphates and other organic acids.

Question 107

A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?

Answer 107

Oliguria Explanation: During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.

Question 108

The nurse is providing care for a patient in the hospital scheduled for discharge in the morning. The patient will require further services after discharge since recovery is not complete. What can the nurse do to ensure quality care delivery for this patient?

Answer 108

Contact the case manager for coordination of care prior to discharge of the patient. Explanation: Coordination of care for patients from the time of hospital admission to discharge-and in many cases after discharge to the home care and community settings-is vitally important to ensure that they continue to achieve benchmarks of quality. Care coordination failure occurs when a patient is readmitted to the hospital shortly after discharge with the same condition for which he or she had been originally hospitalized. Health insurance plans are increasingly holding hospitals accountable for readmissions to the hospital within 30 days of hospital discharge, and many times the plans will not reimburse hospitals for costs associated with these readmissions. Therefore, patient care must be coordinated seamlessly from the inpatient hospital environment through the community care system. However, the current U.S. and Australian and New Zealand health care systems has been frequently criticized for its fragmented system of delivery. Two roles have evolved to provide improved care coordination: the case manager and the clinical nurse leader (CNL). The case manager role has evolved in Australia and New Zealand whereas the CNL role has not.

Question 109

A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document?

Answer 109

advance directive Explanation: An advance directive provides the means for clients to communicate their wishes regarding life-sustaining treatment and other medical care, so that their significant others will know what decisions the clients desire. The two types of advance directives are the living will and durable power of attorney for healthcare. Informed consent is voluntary permission granted by a client or the client's healthcare proxy for a treatment, procedure, or surgery to be performed. A form is used to obtain this consent. A durable power of attorney is a legal document that appoints a person to act as an agent for another person. A DPOA for healthcare appoints a person to make medical decisions for a client who is incapacitated and unable to make decisions for himself or herself. Do-not-resuscitate (DNR) orders involve a written medical order for end-of-life instructions. If a DNR order is written, the client wishes to have no resuscitative action taken if he or she experiences a cardiac arrest.

Question 110

A terminally ill client asks the nurse, “Am I dying?” The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question? Select all that apply.

Answer 110

It is essential that nurses freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone involved. Improved interdisciplinary communication is supported when all members of the health care team can voice concerns and come to an understanding of the moral situation. Consultation with an ethics committee could be helpful to assist the health care team, client, and family to identify the moral dilemma and possible approaches to the dilemma. Nurses should be familiar with agency policy supporting patient self-determination and resolution of ethical issues. The nurse should speak the truth (veracity) to the client, which entails providing correct information and not saying "you will be fine" when this is not the case. Because the client has asked the nurse the question, the nurse should be the one to speak to the client; the nurse should not have the health care provider answer the client.

Question 111

A nurse is leading a community health clinic. What should the nurse emphasize in order to promote disease prevention?

Answer 111

It is best achieved by exhibiting behaviors that promote health. Explanation: Today, increasing emphasis is placed on health, health promotion, wellness, and self-care. Health is seen as resulting from a lifestyle oriented toward wellness. Nurses in community health clinics do not teach that disease prevention is best achieved through attending self-help groups, by reducing stress, or by being an active participant in the community, though each of these activities is consistent with a healthy lifestyle.

Question 112

The nurse is caring for a client who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The client has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?

Answer 112

Obtain a physician’s order to restrain the client. Explanation: It is mandatory in most settings to have a physician’s order before restraining a client. Before restraints are used, other strategies, such as asking family members to sit with the client, or utilizing a specially trained sitter, should be tried. A client should never be left alone while the nurse summons assistance.

Question 113

To address the needs of a chronically ill patient and promote the concept of wellness, a nursing care plan should outline steps to:

Answer 113

Encourage positive health characteristics within the limits of the disease. Explanation: Those with chronic illnesses do have the potential to attain a high-level of wellness within the limits of their disability or illness. The focus of nursing care should be to emphasize a positive approach to coping with the illness. Therefore, the best approach for nursing care is to encourage appropriate health behaviors, promote a sense of hopefulness, and help the patient recognize when his or her limits have been reached. Discussing possible negative complications is not relevant. Also, promoting unnecessary restrictions or activities beyond a patient's ability is not necessary.

Question 114

The nurse needs to perform an admission assessment for a client who does not speak the same language as the nurse. The client’s wife is fluent in both the nurse's and the client's languages. When completing the physical assessment is critical in planning patient care, how should the nurse proceed?

Answer 114

Obtain a translator to assist with interpretation during admission assessment. Explanation: Translation services should be provided for non-English-speaking patients. Asking the patient’s wife violates the patient’s confidentiality. Physical findings alone are not sufficient; the nurse must understand the patient’s interpretation of the physical findings to provide culturally competent nursing care. Completion of the admission assessment in privacy and documenting the language barrier does not address the need for interpretation of the patient’s history, perception, and description of assessment findings.

Question 115

The RN develops an outcome standard of “client will ambulate with an assistive device 60 feet with assistance twice a day” for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?

Answer 115

Planning Explanation: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.

Question 116

The nurse informs the administrative assistant that a client is expected to come in for lab work. The administrative assistant asks why the nurse refers to the individual as a client. What is the best response by the nurse?

Answer 116

"Using the term client implies that they are an active partner in nursing care." Explanation: A client is an active partner in nursing care, and the person receiving healthcare services should no longer play a passive, ill role. The use of the term client reflects the attitude of personal responsibility for health. Though clients may be paying for these services, some physicians may request their staff members to use this terminology, and some people may consider it to be a more respectful term than “patient”, these are not the primary reasons to refer to the individual as a client.

Question 117

Which source of information helps the nurse formulate nursing diagnoses for a specific client?

Answer 117

Essential assessment data Explanation: In the diagnostic phase of the nursing process, the client's nursing problems are defined through analysis of client data. Establishing a plan comes after collecting and analyzing data, evaluating a plan is the last step of the nursing process, and assigning a positive value to each consequence is not done.

Question 118

Which element is involved in the planning phase of the nursing process?

Answer 118

Identify measurable outcomes Explanation: The planning step of the nursing process involves identifying measurable outcomes, selecting nursing interventions, and documenting the planning steps. The implementation step involves carrying out nursing orders. The diagnosis step involves identifying collaborative problems. Completing a health history is done in the assessment step.

Question 119

Which of the following is a cognitive or mental activity that nurses use in critical thinking?

Answer 119

Drawing on past clinical experiences and knowledge to explain what is happening Explanation: Intellectual skills used in critical thinking include drawing on past clinical experiences and knowledge to explain what is happening, priority setting with timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.

Question 120

A nurse preparing a presentation about the practice of nursing for a group of first-year nursing students plans to incorporate the American Nurses Association phenomena of care. Which of the following would the nurse include? Select all that apply.

Answer 120

The American Nurses Association has identified the following phenomena as the focus of nursing care: self-care processes; emotions related to health and illness; transitions across the lifespan; decision-making and ability to make choices. Although culture and ethics are important components of nursing practice, they are not identified as phenomena of care.

Question 121

A nurse chooses a quiet, private area to conduct an end-of-shift report to the oncoming nurse. Following this procedure is necessary because of what ethical problem in nursing?

Answer 121

The right of confidentiality is essential to protect each client's private information. Explanation: Confidentiality is essential to protect the rights of clients. The Health Insurance Portability and Accountability Act (HIPPA) is federal legislation to protect client privacy. Violation of this act could result in criminal or civil litigation. Logging off the computer ensures no one readily has access to client information.

Question 122

A client comes to the clinic and reports being ill for several weeks but does not have insurance and has delayed care. What does the nurse understand about the overall healthcare reform goals that will address issues such as this client?

Answer 122

The goal of healthcare reform is to provide affordable healthcare to more citizens. Explanation: The overall goal of healthcare reform is to provide affordable healthcare to more U.S. citizens. Other goals are to reduce the insurance companies' control of healthcare and to provide more assistance to senior citizens on fixed incomes. Providing care to women, infants, and children and offering more healthcare programs to address illness may be results of healthcare reform but are not themselves the overall goal. Healthcare reform seeks to provide quality healthcare that is affordable to as many U.S. citizens as possible, not to only provide it to those who can already afford it.

Question 123

Which type of nursing diagnosis identifies potential problems that may arise due to the client’s disease, condition, or situation?

Answer 123

risk Explanation: Risk nursing diagnoses identify potential problems and use the stem "risk for" as in Risk for Impaired Skin IntegrityAltered Skin Integrity Risk related to inactivity. The actual diagnosis identifies an existing problem such as Urinary Retention or Acute Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The syndrome diagnosis describes specific diagnoses that occur as a group.

Question 124

Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses?

Answer 124

Critical thinking Explanation: Critical thinking requires going beyond basic problem-solving and results in comprehensive plans of care.

Question 125

Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care?

Answer 125

Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis Explanation: Cystic fibrosis is an autosomal recessive genetic disorder. Parents of a child diagnosed with cystic fibrosis have a 50% chance of having another child with cystic fibrosis. Once the nurse assesses the family history, it is appropriate nursing action to for the nurse to make a referral for genetic testing or counseling. Although ADHD may have a genetic component, there is no genetics-related issue in this situation. Lead poisoning is not a genetic disorder. There is no indication that any of the children in the blended family have a genetics-related problem.

Question 126

A nurse is beginning a health history with a client and states, "Which part of your health history would you like to start with?" This type of communication technique is called

Answer 126

Broad opening Explanation: Broad opening encourages the client to select topics for discussion, which indicates acceptance by the nurse and the value of the client's initiative. Suggesting involves presentation of alternative ideas for the client's consideration relative to problem solving. Listening is an active process of receiving information and examining one's reactions to the messages received. Silence is described as periods of no verbal communication among participants for therapeutic reasons.

Question 127

Which ethical principle is related to the duty to do good?

Answer 127

Beneficence Explanation: Beneficence is the duty to do good to benefit others and the active promotion of benevolent acts. Autonomy refers to self-rule. Confidentiality related to the concept of privacy. Nonmaleficence is the duty not to inflict harm as well as to prevent and remove harm.

Question 128

Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following?

Answer 128

Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups Explanation: Community-oriented nursing practice focuses on nursing interventions that can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens or the community at large. Community-based nursing and home health care is directed toward specific client groups with identified needs, which usually relate to illness, injury, or disability, resulting most often from advanced age or chronic illness. Community nursing centers are nurse managed and provide primary care, often to underserved populations. Home care nursing is a specialty area that provides care in the home and community to meet the needs of clients who are discharged from acute care institutions to their homes and communities early in the recovery process and with complex needs.

Question 129

A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client?

Answer 129

The client will demonstrate an ability to feed himself with a spoon at the morning meal. Explanation: Outcomes are expressed in terms of client behavior and have a time period in which they are to be achieved. The outcome is associated with the nursing diagnosis. In this case, the diagnosis reflects a self-feeding problem caused by weakness. Therefore, being able to feed oneself would be a client behavior the nurse would expect to see achieved.

Question 130

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The client is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique?

Answer 130

Informing Explanation: Informing involves providing information to the client regarding his or her care. Suggesting is the presentation of an alternative idea for the client's consideration relative to problem-solving. This action is not characterized as expectation setting or enlightening.

Question 131

Which critical thinking skill involves identification of client problems indicated by data?

Answer 131

Analysis Explanation: Analysis is used to identify client problems indicated by data. Interpretation is used to determine the significance of data that are gathered. Inference is used by the nurse to draw conclusions. Explanation is the justification of actions or interventions used to address client problems and to help a client move toward desired outcomes.

Question 132

A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse’s duty to tell the truth?

Answer 132

veracity Explanation: Veracity is the nurse's duty to tell the truth in all professional situations. Autonomy refers to a client's right to self-determination. Beneficence is the duty to do good for the clients assigned to the nurse's care. Nonmaleficence is the duty to do no harm to the client.

Question 133

A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include?

Answer 133

Participation in decision making that is shared by all involved Explanation: The collaborative practice model involves all care providers, including nurses, physicians, and ancillary health personnel as well as the patient functioning within a decentralized organizational structure to collaboratively make clinical decisions. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment that strives to meet the complex health care needs of the public.

Question 134

A nurse working in a community-based health center is engaged in teaching a client about her medications. The nurse is acting as which of the following?

Answer 134

Practitioner Explanation: A nurse who works in a community-based setting and provides education to clients is acting in the practitioner role. The leadership role involves those actions executed when assuming responsibility for the actions of others directed at determining and achieving client care goals. The researcher role involves identifying nursing problems and important issues related to client care and initiating and implementing timely, relevant studies. Delegating is a component of the leadership role.

Question 135

A client is to be discharged from an acute care facility after treatment for pneumonia. The nurse notes that the client's lungs are clear and denies shortness of breath. The nurse's actions reflect which step of the nursing process?

Answer 135

Evaluation Explanation: Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved. The other answers are incorrect because they are not the correct phase of the nursing process.

Question 136

The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN’s contribution to the plan?

Answer 136

Data gathering, identification of client strengths, and assurance of client safety during the assessment phase Explanation: Establishment of priorities, identification of problems and risks, and delegation and management of client care are all roles of the registered nurse during the nursing process. Data gathering, identification of client strengths, performance of assessments and assurance of client safety are role of the LPN when using the nursing process to develop the client plan of care.

Question 137

Which therapeutic communication technique may occur during the planning stage, when the client is presented with alternative ideas for consideration relative to problem solving?

Answer 137

Suggesting Explanation: Suggesting is the presentation of alternative ideas for the client's consideration relative to problem solving. Clarification is asking the client to explain what he or she means or attempting to help verbalize the client's vague ideas or unclear thoughts to enhance the nurse's understanding. Focusing includes questions or statements to help the client develop or expand an idea.

Question 138

A nurse is planning a medical client's care with consideration of Maslow hierarchy of needs. Within this framework of understanding, what should the nurse prioritize?

Answer 138

Administering pain medication Explanation: In Maslow hierarchy of needs, pain relief addresses the client's basic physiologic need. Activity, such as ambulation, is a higher level need above the physiologic need. Allowing the client to see family addresses a higher level need related to love and belonging. Teaching the client is also a higher level need related to the desire to know and understand and is not appropriate at this time, as the basic physiologic need of pain control must be addressed before the client can address these higher level needs.

Question 139

A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow’s theories on human needs, what is the reason the client refuses to participate in activities?

Answer 139

The client likes to go to have a nap in afternoon and go to bed early in the evening. Explanation: According to Maslow, the client would need to be sure that basic physiologic and safety and security needs were being met before becoming interested in meeting love and belonging (social) needs. The client needs to have physical needs met like food, sleep, and bowel elimination before requiring increased self-esteem through social activities.

Question 140

Which of the following is stated in a living will?

Answer 140

Wishes regarding healthcare if terminally ill Explanation: A living will is a document that states a client's wishes regarding healthcare if the client is terminally ill. It is not necessarily a legal consent. A client may designate another person to be the medical durable power of attorney or healthcare proxy. Do-not-resuscitate orders contain written medical prescriptions for end-of-life instructions.

Question 141

Which is a goal of case management?

Answer 141

Appropriateness of services Explanation: The goals of care management are to ensure the quality, appropriateness, and timeliness of services as well as to reduce costs. Case managers do not have prescriptive authority. Fixed price reimbursement is a feature of managed care. Case managers do not utilize the nursing process.

Question 142

Which of the following would least likely impact health care delivery and nursing?

Answer 142

Decline in genetic focus Explanation: Factors impacting health care delivery and nursing include growth in the population, increasing cultural diversity, increased consumer knowledge, and advances in technology and genetics.

Question 143

A nurse is unsure how best to respond to a client's vague complaint of “feeling off.” The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition?

Answer 143

By examining the way that she thinks and applies reason Explanation: Critical thinking includes metacognition, the examination of one's own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.

Question 144

Which intellectual skill is used by nurses when thinking critically?

Answer 144

Supporting evidence with facts Explanation: Intellectual skills used in critical thinking include supporting evidence with facts, setting priorities through timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.

Question 145

When a person authorizes another to make medical decisions on his or her behalf, the person has written which of the following?

Answer 145

Proxy directive Explanation: Durable power of attorney for health care is a legal document through which the signer appoints and authorizes another individual to make medical decisions on his or her behalf when he or she is no longer able to speak for him- or herself. This is also known as a health care power of attorney or a proxy directive.

Question 146

A nurse is speaking to a group of prospective nursing students about what it is like to be a nurse. What characteristic should the nurse cite as necessary to possess to be an effective nurse?

Answer 146

Sensitivity to cultural differences Explanation: To promote an effective nurse–client relationship and positive outcomes of care, nursing care must be culturally competent, appropriate, and sensitive to cultural differences. Problem-solving in nursing often requires collaboration. The ability to handle criticism is important, but it is unrealistic to expect to be unaffected by it.

Question 147

Which of the following is stated in a living will?

Answer 147

Wishes regarding healthcare if terminally ill Explanation: A living will is a document that states a client's wishes regarding healthcare if the client is terminally ill. It is not necessarily a legal consent. A client may designate another person to be the medical durable power of attorney or healthcare proxy. Do-not-resuscitate orders contain written medical prescriptions for end-of-life instructions.

Question 148

The nurse is developing a nursing diagnosis for a client. Which information should be included in the nursing diagnosis? Choose all that apply.

Answer 148

When choosing nursing diagnoses for a particular client, nurses must first identify the commonalities among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. To give additional meaning to the nursing diagnosis, the characteristics and the etiology of the problem are identified and included as part of the diagnosis. The other choices are not part of the process to develop a nursing diagnosis.

Question 149

The nurse is caring for a 90-year-old client who has never completed an advance directive. The client has a child but has not seen the child in several years. A neighbor has assisted the client with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged offspring wants the client to be treated aggressively. Which would be the nurse's initial step?

Answer 149

Assess the client's ability to state wishes. Explanation: It cannot be assumed that the client is unable to make decisions independently because of advanced age. Before any other person is asked about the client's wishes, the client needs to be asked first. The physician, who has a healthcare relationship with the client, may also have documented information about wishes.

Question 150

A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth?

Answer 150

Provide gentle oral care after each meal. Explanation: Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.

Question 151

Which action by the nurse demonstrates an effective method to assess the client and the client’s family’s ability to cope with end-of-life interventions?

Answer 151

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Explanation: A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."

Question 152

A nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan?

Answer 152

The stages are applicable to any loss. Explanation: The five stages of dying describe the five emotional reactions applicable to the experience of any loss. Not every client or family member experiences every stage. Many clients never reach a stage of acceptance. Clients and family fluctuate on a sometimes daily basis in their emotional responses.

Question 153

Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care?

Answer 153

"Tell me who or what gives you strength." Explanation: Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors.

Question 154

In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea?

Answer 154

Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help potentiate the effects of pain medication.

Question 155

A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client?

Answer 155

"Let's take this one day at a time; remember you have your daughter's dance recital next week." Explanation: Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.

Question 156

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?

Answer 156

Advice for the family to have fruit juices readily available at the client's bedside. Explanation: To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.

Question 157

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using?

Answer 157

Palliative care Explanation: Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

Question 158

A client states, “My children still need me. Why did I get cancer? I am only 30.” This client is exhibiting which stage according to Kübler-Ross?

Answer 158

Anger Explanation: Anger is the second stage and is exhibited by statement similar to “Why me?” Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.

Question 159

Which is the initial stage of grief, according to Kübler-Ross?

Answer 159

Denial Explanation: The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

Question 160

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

Answer 160

Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

Question 161

The nurse is caring for a client who just learned of a terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?

Answer 161

The principle of autonomy Explanation: By promoting open discussion and informed decision making, the nurse is empowering the client to make decisions independently. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

Question 162

Which “awareness context” is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise?

Answer 162

Mutual pretense awareness Explanation: In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to acknowledge that reality openly.

Question 163

A terminally ill patient is admitted to the hospital. The patient grabs the nurse’s hand and asks, “Am I dying?” What response would be best for the nurse to give?

Answer 163

“Tell me more about what’s on your mind.” Explanation: In response to the question “Am I dying?” the nurse could establish eye contact and follow with a statement acknowledging the patient’s fears (“This must be very difficult for you”) and an open-ended statement or question (“Tell me more about what is on your mind”). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic.

Question 164

A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client?

Answer 164

Palliative sedation Explanation: Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.

Question 165

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?

Answer 165

Respect the client's and family members' choices. Explanation: In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

Question 166

As the moment of death approaches, which of the following does the nurse encourage the family to do?

Answer 166

Speak to the client in a calm and soothing voice. Explanation: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

Question 167

When describing the term "grief" to a group of students, which of the following would the instructor include?

Answer 167

The response experienced by anyone who has suffered a loss Explanation: Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation.

Question 168

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival.

Answer 168

Palliative care Explanation: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.

Question 169

Which term best describes a living will?

Answer 169

Medical directive Explanation: A living will is a type of advance medical directive in which the individual, who is of sound mind, documents treatment preferences. A proxy directive and health care power of attorney are other names for a durable power of attorney for health care, in which one individual is appointed and authorized to make medical decisions on behalf of another person when that person is no longer able to speak for him or herself.

Question 170

Which assessment would a nurse perform on a client with Cushing syndrome who is at high risk of developing a peptic ulcer?

Answer 170

Observe stool color. Explanation: The nurse should observe the color of each stool and test the stool for occult blood.

Question 171

A nurse explains to a client with thyroid disease that the thyroid gland normally produces:

Answer 171

T3, thyroxine (T4), and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. The pituitary gland produces TSH to regulate the thyroid gland. The hypothalamus gland produces TRH to regulate the pituitary gland.

Question 172

Accidental removal of one or both parathyroid glands can occur during a thyroidectomy. Which of the following is used to treat tetany?

Answer 172

Calcium gluconate Explanation: Sometimes in thyroid surgery, the parathyroid glands are removed, producing a disturbance in calcium metabolism. Tetany is usually treated with IV calcium gluconate. Synthroid is used in the treatment of hypothyroidism. PTU and Tapazole are used in the treatment of hyperthyroidism.

Question 173

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?

Answer 173

Pressure on the optic nerve Explanation: Partial blindness may result from pressure on the optic nerve. Glaucoma does not occur suddenly, and the client did not report injury to suspect corneal abrasions or retinal detachment.

Question 174

A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults?

Answer 174

Papillary carcinoma Explanation: Papillary carcinoma accounts for about 70% of thyroid cancer cases in adults. Follicular carcinoma accounts for roughly 15%; anaplastic carcinoma, about 5%; and medullary carcinoma, about 5%.

Question 175

Which of the following hormones would the nurse identify as being secreted by the thyroid gland?

Answer 175

Thyroxine Explanation: The thyroid gland secretes thyroxine (T4 or tetraiodothyronine), triiodothyronine (T3), and calcitonin. Parathormone is secreted by the parathyroid glands. Thymosin is secreted by the thymus gland. Somatotropin is secreted by the anterior pituitary gland.

Question 176

A patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder?

Answer 176

Blood pressure varying between 120/86 and 240/130 mm Hg Explanation: Hypertension associated with pheochromocytoma may be intermittent or persistent. Blood pressures exceeding 250/150 mm Hg have been recorded. Such blood pressure elevations are life threatening and can cause severe complications, such as cardiac dysrhythmias, dissecting aneurysm, stroke, and acute kidney failure.

Question 177

A client is having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress?

Answer 177

Glucocorticoids Explanation: Glucocorticoids, such as cortisol, affect body metabolism, suppress inflammation, and help the body withstand stress. Mineralocorticoids, primarily aldosterone, maintain water and electrolyte balances. The androgenic hormones convert to testosterone and estrogens.

Question 178

A client with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this client?

Answer 178

Decreased blood pressure Explanation: Decreased blood pressure may occur with hypofunction of the adrenal cortex. Decreased function of the adrenal cortex does not affect the client's body temperature, urine output, or skin tone.

Question 179

The nurse assesses a patient who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

Answer 179

Potassium of 6.0 mEq/L Explanation: Addison's disease is characterized by hypotension, low blood glucose, low serum sodium, and high serum potassium levels. The normal serum potassium level is 3.5 to 5 mEq/L.

Question 180

The nurse is aware that the best time of day for the total large corticosteroid dose is between:

Answer 180

7:00 AM and 8:00 AM Explanation: The best time of day for the total large corticosteroid dose is in the early morning, between 7:00 AM and 8:00 AM, when the adrenal gland is most active. Therefore, dosage at this time of day will result in the maximum suppression of the adrenal gland.

Question 181

Parathyroid hormone (PTH) has which effects on the kidney?

Answer 181

Stimulation of calcium reabsorption and phosphate excretion Explanation: PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E.

Question 182

When describing the difference between endocrine and exocrine glands, which of the following would the instructor include as characteristic of endocrine glands?

Answer 182

The secretions are released directly into the blood stream. Explanation: The endocrine glands secrete hormones, chemicals that accelerate or slow physiologic processes, directly into the bloodstream. This characteristic distinguishes endocrine glands from exocrine glands, which release secretions into a duct. Hormones circulate in the blood until they reach receptors in target cells or other endocrine glands. They play a vital role in regulating homeostatic processes.

Question 183

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Answer 183

Decreased cardiac output Explanation: An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.

Question 184

A patient is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the patient will experience?

Answer 184

A decrease in urine output Explanation: Desmopressin (DDAVP), a synthetic vasopressin without the vascular effects of natural ADH, is particularly valuable because it has a longer duration of action and fewer adverse effects than other preparations previously used to treat the disease. DDAVP and lypressin (Diapid) reduce urine output to 2 to 3 L/24 hours. It is administered intranasally; the patient sprays the solution into the nose through a flexible calibrated plastic tube. One or two administrations daily (i.e., every 12 to 24 hours) usually control the symptoms (Papadakis, McPhee, & Rabow, 2013). Vasopressin causes vasoconstriction; thus, it must be used cautiously in patients with coronary artery disease.

Question 185

A client sustained a head injury when falling from a ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8-pound weight loss since admission. What condition does the nurse expect the client to be tested for?

Answer 185

Diabetes insipidus (DI) Explanation: With diabetes insipidus, urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine excretion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop. SIADH will have the opposite clinical manifestations. The client's symptoms are related to the trauma and not to a pituitary tumor. The thyroid gland does not exhibit these symptoms.

Question 186

The nurse is preparing a client for a thyroid test. Which medications that the client is taking should be documented on the laboratory slip as possibly affecting the thyroid test?

Answer 186

If a client has recently taken a drug that contains iodine or has had radiographic contrast studies that used iodine, thyroid test results may be inaccurate. Other drugs also affect the results of thyroid tests. Phenytoin can lower T4 values. Metoclopramide can raise TSH levels. Amphetamine can lower TSH levels. Furosemide can increase T4 level. Be sure to enter on the laboratory request slip all drugs the client is taking or has taken within the past 3 months. The other drugs do not have relevance to the thyroid test.

Question 187

Which condition may occur during the postoperative period in a client who underwent adrenalectomy because of sudden withdraw of excessive amounts of catecholamines?

Answer 187

Hypoglycemia Explanation: Hypotension and hypoglycemia may occur in the postoperative period because of the sudden withdrawal of excessive amounts of catecholamines. Hypertension and hyporeflexia are not related to the sudden withdraw of excessive amounts of catecholamines.

Question 188

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:

Answer 188

sodium and potassium abnormalities. Explanation: In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

Question 189

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

Answer 189

Sodium level of 150 mEq/L Explanation: Diabetes insipidus (DI) is a rare disorder that occurs due to injury to the hypothalamus or pituitary gland with a deficiency of ADH (vasopressin) that results in excretion of large volumes of dilute urine and extreme thirst. Without the action of ADH on the distal nephron of the kidney, an enormous daily output (greater than 250 mL per hour) of very dilute urine with a specific gravity of 1.001 to 1.005 occurs. The urine contains no abnormal substances such as glucose or albumin. Due to the intense thirst, the client tends to drink 2 to 20 L of fluid daily and craves cold water. In adults, the onset of DI may be insidious or abrupt. The disease cannot be controlled by limiting fluid intake because the high-volume loss of urine continues even without fluid replacement. Attempts to restrict fluids cause the client to experience an insatiable craving for fluid and to develop hypernatremia and severe dehydration. DI does not affect the glucose, potassium, or phosphate levels.

Question 190

The nurse is teaching a client about the dietary restrictions related to his diagnosis of hyperparathyroidism. What foods should the nurse encourage the client to avoid?

Answer 190

Milk Explanation: Clients with hyperparathyroidism should use a low-calcium diet (fewer dairy products) and drink at least 3 to 4 L of fluid daily to dilute the urine and prevent renal stones from forming. It is especially important that the client drink fluids before going to bed and periodically throughout the night to avoid concentrated urine. Bananas, chicken livers, and hamburgers do not require avoidance. Milk is the highest in calcium content.

Question 191

When thyroid hormone is administered for prolonged hypothyroidism for a patient, what should the nurse monitor for?

Answer 191

Angina Explanation: Angina or dysrhythmias can occur when thyroid replacement is initiated because thyroid hormones enhance the cardiovascular effects of catecholamines.

Question 192

A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland?

Answer 192

Adrenal cortex Explanation: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

Question 193

Vision and visual fields are altered in disorders of which of the following endocrine glands?

Answer 193

Pituitary Explanation: The pituitary gland is located close to the optic nerves and hence causes pressure on these nerves; thus, changes in the vision and the visual fields may occur.

Question 194

Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences:

Answer 194

heat intolerance and systolic hypertension. Explanation: An increased metabolic rate in a client with hyperthyroidism caused by excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss — not gain — occurs because of the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat intolerance and widened pulse pressure can occur but systolic hypertension and diastolic hypertension don't. Clients with hyperthyroidism experience an increase in appetite — not anorexia.

Question 195

An instructor has just finished teaching a class about the endocrine system. The instructor determines that the students need additional instruction when they identify which of the following as an endocrine gland?

Answer 195

Kidneys Explanation: Although the kidneys secrete renin and erythropoietin, they are typically not considered endocrine glands. Therefore, if the students identify the kidneys as endocrine glands, they need further instruction. The pancreas, adrenal glands, and testes are considered endocrine glands.

Question 196

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by:

Answer 196

a corticotropin-secreting pituitary adenoma. Explanation: A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are commonly associated with weight loss. Adrenal carcinoma isn't usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn't be menstruating.

Question 197

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of:

Answer 197

fresh fruits. Explanation: Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase the intake of potassium-rich foods, such as fresh fruit. The client should restrict the consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium. Although the client should consume foods high in calcium and protein, the client should find these nutrients in low-sodium foods.

Question 198

A patient who is diagnosed with type 1 diabetes would be expected to:

Answer 198

Need exogenous insulin. Explanation: Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.

Question 199

A client with a 30-year history of type 2 diabetes is having an annual physical and blood work. Which test result would the physician be most concerned with when monitoring the client's treatment compliance?

Answer 199

glycosylated hemoglobin Explanation: Once a client with diabetes receives a treatment regimen to follow, the physician can assess the effectiveness of treatment and the client's compliance by obtaining a hemoglobin A1c test. The results of this test reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. Normally, the level of glycosylated hemoglobin is less than 7%. Amounts of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.

Question 200

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Answer 200

Presence of islet cell antibodies Explanation: Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.

Question 201

A client is diagnosed with diabetes mellitus. The client reports visiting the gym regularly and is a vegetarian. Which of the following factors is important to consider when the nurse assesses the client?

Answer 201

The client's consumption of carbohydrates Explanation: While assessing a client, it is important to ask about consumption of carbohydrates due to the client’s high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not the priority when assessing a client with high blood sugar.

Question 202

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

Answer 202

The client has eaten and has not taken or received insulin. Explanation: If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than usual.

Question 203

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

Answer 203

ketoacidosis Explanation: Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.

Question 204

The nurse suspects that a patient with diabetes has developed proliferative retinopathy. The nurse confirms this by the presence of which of the following diagnostic signs?

Answer 204

Neovascularization into the vitreous humor Explanation: Proliferative retinopathy, an ocular complication of diabetes, occurs because of the abnormal growth of new blood vessels on the retina that bleed into the vitreous and block light. Blood vessels in the vitreous form scar tissue that can pull and detach the retina. Neovascularization into the vitreous humor is considered a diagnostic sign.

Question 205

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective?

Answer 205

1/2 cup fruit juice or regular soft drink Explanation: In a client with hypoglycemia, the nurse uses the rule of 15: give 15 g of rapidly absorbed carbohydrate, wait 15 minutes, recheck the blood sugar, and administer another 15 g of glucose if the blood sugar is not above 70 mg/dL. One-half cup fruit juice or regular soft drink is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Eight ounces of skim milk is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. One tablespoon of honey or syrup is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Six to eight LifeSavers candies is equivalent to the recommended 15 g of rapidly absorbed carbohydrate.

Question 206

The client with diabetes asks the nurse why shoes and socks are removed at each office visit. The nurse gives which assessment finding as the explanation for the inspection of feet?

Answer 206

Sensory neuropathy Explanation: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The client's feet are inspected on each visit to ensure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

Question 207

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which condition when caring for this client?

Answer 207

Hypoglycemia Explanation: The nurse should observe the client receiving an oral antidiabetic agent for signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

Question 208

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Answer 208

Metformin Explanation: Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

Question 209

A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:

Answer 209

polyphagia. Explanation: While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose.

Question 210

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

Answer 210

10 to 15 minutes Explanation: The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

Question 211

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?

Answer 211

Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

Question 212

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, “You look anorexic.” Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

Answer 212

"Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

Question 213

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

Answer 213

The client has not eaten but continues to take insulin or oral antidiabetic medications. Explanation: Hypoglycemia occurs when a client with diabetes is not eating and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the client has not been compliant with the prescribed treatment regimen. If the client has eaten and has not taken or received insulin, diabetic ketoacidosis is more likely to develop.

Question 214

A client with type 1 diabetes is to receive a short-acting insulin and an intermediate-acting insulin subcutaneously before breakfast. The nurse would administer the insulin at which site as the preferred site?

Answer 214

Abdomen Explanation: Although the arms, thighs, and lower back can be used, the preferred site insulin administration is the abdomen which allows more rapid absorption.

Question 215

Lispro (Humalog) is an example of which type of insulin?

Answer 215

Rapid-acting Explanation: Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).

Question 216

The pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar:

Answer 216

The pancreatic hormone glucagon will stimulate the liver to release stored glucose. Explanation: When sugar levels are low, glucagon promotes hyperglycemia by stimulating the release of stored glucose. Glycogenolysis and gluconeogenesis will both be increased. Insulin secretion would promote hypoglycemia.

Question 217

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

Answer 217

"Test your blood glucose every 4 hours." Explanation: The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

Question 218

Which information should be included in the teaching plan for a client receiving glargine, a “peakless” basal insulin?

Answer 218

Do not mix with other insulins. Explanation: Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine insulin, it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Question 219

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

Answer 219

Hypokalemia and hypoglycemia Explanation: Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

Question 220

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

Answer 220

at least three times per week. Explanation: Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.

Question 221

The nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. What is an important dietary consideration for the nurse to keep in mind?

Answer 221

Encourage midday snack. Explanation: Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 10 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.

Question 222

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Answer 222

Blood glucose level 1,100 mg/dl Explanation: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

Question 223

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?

Answer 223

Albumin Explanation: Nephropathy, or kidney disease secondary to diabetic microvascular changes in the kidney, is a common complication of diabetes. Consistent elevation of blood glucose levels stresses the kidney’s filtration mechanism, allowing blood proteins to leak into the urine and thus increasing the pressure in the blood vessels of the kidney. Albumin is one of the most important blood proteins that leak into the urine, and its leakage is among the earliest signs that can be detected. Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria but in fewer than 5% of people without microalbuminuria. The urine should be checked annually for the presence of proteins, which would include microalbumin.

Question 224

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Answer 224

Coma, anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mg/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

Question 225

NPH is an example of which type of insulin?

Answer 225

Intermediate-acting Explanation: NPH is an intermediate-acting insulin.

Question 226

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

Answer 226

"You'll need less insulin when you exercise or reduce your food intake." Explanation: The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

Question 227

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

Answer 227

The short-acting insulin is withdrawn before the intermediate-acting insulin. Explanation: When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy."

Question 228

A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of “sick days.” The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse’s best response?

Answer 228

"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Explanation: Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

Question 229

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

Answer 229

15 g of carbohydrates. Explanation: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

Question 230

Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:

Answer 230

Synthesis of glucose from noncarbohydrate sources. Explanation: Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.

Question 231

A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply.

Answer 231

Insulin is a hormone secreted by the endocrine part of the pancreas. In addition to lowering blood glucose by permitting entry of glucose into the cells, insulin also promotes protein synthesis and the storage of fat in adipose tissue. Somatostatin exerts a hypoglycemic effect by interfering with glucagon from the pancreas and the release of growth hormone from the pituitary.

Question 232

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

Answer 232

Increased urine output Explanation: Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

Question 233

What is the duration of regular insulin?

Answer 233

4 to 6 hours Explanation: The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.

Question 234

When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day?

Answer 234

3 AM Explanation: During the dawn phenomenon, the patient has a relatively normal blood glucose level until about 3 AM, when the level begins to rise.

Question 235

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?

Answer 235

Fruity breath Explanation: The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.

Question 236

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

Answer 236

They increase the need for insulin. Explanation: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.

Question 237

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

Answer 237

High sugar pulls fluid into the bloodstream, which results in more urine production. Explanation: The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

Question 238

A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy via an insulin pump. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

Answer 238

rapid-acting insulin only. Explanation: A continuous subcutaneous insulin regimen uses a basal rate and boluses of rapid-acting insulin. Multiple daily injection therapy uses a combination of rapid-acting and intermediate- or long-acting insulins.

Question 239

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

Answer 239

Rapid, thready pulse Explanation: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.