Exam Two - Practice Q's Flashcards
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?
A) The scars on my liver create problems with blood circulation
B) My liver is scarred, but the cells can regenerate themselves and repair the damage
C) Because of the scars on my liver, blood clotting and BP are affected
D) Cirrhosis is a chronic disease that has scarred my liver
B) My liver is scarred, but the cells can regenerate themselves and repair the damage
The nurse is caring for a client who has cirrhosis of the liver. The client’s latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor?
A) DVT
B) Jaundice
C) Hematemesis
D) Pressure injury
C) Hematemesis
How would the home care nurse best modify the client’s home environment to manage side effects of lactulose?
A) Obtains a walker for the client
B) Rearranges furniture to declutter the home
C) Removes throw rugs to prevent falls
D) Requests a bedside commode for the client
D) Requests a bedside commode for the client
When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure?
A) Assist the provider to insert a tracer catheter into the abdomen
B) Position the client with the head of the bed flat
C) Encourage the client to take deep breaths and cough
D) Ask the client to void prior to the procedure
D) Ask the client to void prior to the procedure
The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse’s priority assessment during client care?
A) Cardiovascular assessment
B) Abdominal assessment, including bowel sounds
C) Respiratory assessment
D) Cognitive and neurologic assessment
D) Cognitive and neurologic assessment
The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching?
A) Calcium
B) Potassium
C) Sodium
D) Magnesium
C) Sodium
The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective?
A) Increased BP
B) Decreased weight
C) Increased pulse
D) Decreased pain
B) Decreased weight
The nurse is teaching a client and family about home care following a transjugular intrahepatic portal systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately?
A) Decreased ascitic fluid
B) Changes in consciousness or behavior
C) Fatigue and weakness
D) Decreased pulse rate
B) Changes in consciousness or behavior
Client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status and/or behavior.
The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse?
A) These interventions help to reduce the ammonia level
B) These interventions help to prevent heart failure
C)These interventions help the client’s jaundice improve
D) These interventions help to prevent nausea and vomiting
A) These interventions help to reduce the ammonia level
The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client’s hepatitis A?
A) Being exposed to blood or blood products
B) Eating contaminated food or water
C) Having unprotected sex
D) Sharing needles for illicit drugs
B) Eating contaminated food or water
When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B?
A) Clients who work with shellfish
B) Clients with elevations of aspartate aminotransferase and alanine aminotransferase
C) Men who engage in sex with men
D) Clients traveling to a third-world country
C) Men who engage in sex with men
It is essential that the nurse monitor the client retuning from hepatic artery embolization for hepatic cancer for which potential complication?
A) Right shoulder pain
B) Bone marrow suppression
C) Polyuria
D) Bleeding
D) Bleeding
What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection?
A) Drink only bottled water and avoid ice
B) Avoid sharing the bathroom with the client
C) Members of the household must not share toothbrushes
D) The client must not consume alcohol
C) Members of the household must not share toothbrushes
Which action by the nurse would most likely help to relieve symptoms associated with ascites?
A) Monitoring serum albumin levels
B) Lowering the head of the bed
C) Administering oxygen therapy
D) Administering intravenous fluids
C) Administering oxygen therapy
The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor?
A) Acute kidney injury
B) Hypertension
C) Pulmonary edema
D) Infection
D) Infection
When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? SATA
A) Elevated magnesium
B) Swollen abdomen
C) Prolonged partial thromboplastin time
D) Elevated amylase level
E) Currant jelly stool
F) Icterus of skin
B) Swollen abdomen
C) Prolonged partial thromboplastin time
F) Icterus of skin
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? SATA
A) Right upper quadrant tenderness
B) Itching
C) Recent influenza infection
D) Brown stool
E) Tea-colored urine
A) Right upper quadrant tenderness
B) Itching
E) Tea-colored urine
When caring for a client with portal hypertension, the nurse assesses for which potential complications? SATA
A) Esophageal varices
B) Ascites
C) Hematuria
D) Hemorrhoids
E) Fever
A) Esophageal varices
B) Ascites
D) Hemorrhoids
The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? SATA
A) Smoking
B) Alcohol
C) Illicit drugs
D) Acetaminophen
E) Sodium
F) Protein
A) Smoking
B) Alcohol
C) Illicit drugs
D) Acetaminophen
The nurse is caring for a client who has been diagnosed with cirrhosis. Which lab result(s) would the nurse expect for this client? SATA
A) Increased serum bilirubin
B) Increased lactate dehydrogenase
C) Decreased serum albumin
D) Increased serum alanine aminotransferase
E) Increased aspartate aminotransferase
F) Increased serum ammonia
A) Increased serum bilirubin
B) Increased lactate dehydrogenase
C) Decreased serum albumin
D) Increased serum alanine aminotransferase
E) Increased aspartate aminotransferase
F) Increased serum ammonia
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is priority for the client at this time?
A) Positioning the client to maximize ventilation potential
B)Taking vital signs Q2hours
C) Inserting an indwelling urinary catheter
D) Monitoring the client’s nutritional status
A) Positioning the client to maximize ventilation potential
To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority?
A) Nutritional therapy
B) Physical therapy
C) Respiratory therapy
D) Occupational therapy
C) Respiratory therapy
A client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates a need for further teaching?
A) It’s important I work out in the afternoon so my muscles are warmed up
B) I can alternate wearing my eye patch between eyes for double vision
C) I should keep my home clutter free so I don’t fall
D) I always keep my medications in the same place
A) It’s important I work out in the afternoon so my muscles are warmed up
A client returns to the neurosurgical floor after undergoing a traditional anterior cervical diskectomy and fusion (ACDF). What is the nurse’s first action?
A) Check the client’s ability to void
B) Administer pain medication
C) Assist with ambulation
D) Assess airway and breathing
D) Assess airway and breathing
The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication?
A) Nifedipine
B) Dopamine hydrochloride
C) Ziconotide
D) Methylprednisone
A) Nifedipine
A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first?
A) Check for fecal impaction
B) Help the client sit up
C) Loosen the client’s clothing
D) Insert a straight catheter
B) Help the client sit up
The nurse’s first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension.
A client with possible multiple sclerosis asks the nurse to explain why she has to have a visual evoked response (VER) test. What statement by the nurse is correct about this diagnostic test?
A) “A group of electrodes will be placed on your scalp so to see how your eyes react.”
B) “You will have to lie very still in a tube for the magnetic imaging of your head and neck.”
C) “This test will help determine how well the nerves in your eyes transmit a signal.”
D)“A contrast medium will be used to visualize any changes in your brain.”
C) “This test will help determine how well the nerves in your eyes transmit a signal.”
A family member of a client with a recent spinal cord injury asks the nurse, “Can you please tell me what the real prognosis for recovery is? I don’t feel like I’m getting a straight answer.” What would be the appropriate response for the nurse?
A) “Only time will tell, but hopefully the client will be able to care for yourself.”
B) “Every injury is different, and it is too soon to have any real answers right now.”
C) “The Health Insurance Portability and Accountability Act requires that I obtain the client’s permission first.”
D) “Please request a meeting with the primary health care provider. I can help set that up.”
D) “Please request a meeting with the primary health care provider. I can help set that up.”
The nurse is collaborating with the rehabilitation therapist to improve mobility skills for a client with a complete high-level spinal cord injury. Which technique is appropriate for this client?
A) Use of a mechanical lift to get the client out of bed
B) Use of a sliding board (slider) to transfer from bed to a chair
C) Use of parallel bars to facilitate ambulation
D) Use of a walker to promote balance and prevent muscle atrophy
B) Use of a sliding board (slider) to transfer from bed to a chair
Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury?
A) Special pressure-relief devices
B) Frequent ambulation
C) Encouraging nutrition
D) Regular turning and repositioning
D) Regular turning and repositioning
The nurse is providing instructions to a client with a cervical spinal cord injury about caring for the halo fixator device. The nurse plans to include which instructions?
A) “Avoid using a pillow under the head while sleeping.”
B) “Begin driving 1 week after discharge.”
C) “Keep straws available for drinking fluids.”
D) “Swimming is recommended to keep active.”
C) “Keep straws available for drinking fluids.”
The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment findings would the nurse anticipate if this complication occurs? SATA
A) Goosebumps above and/or below the injury level
B) Sudden and severe hypertension
C) Severe throbbing headache
D) Profuse sweating about the injury level
E) Nasal congestion and blurred vision
F) Facial and skin flushing
A) Goosebumps above and/or below the injury level
B) Sudden and severe hypertension
C) Severe throbbing headache
D) Profuse sweating about the injury level
E) Nasal congestion and blurred vision
F) Facial and skin flushing
The nurse is caring for a client who has a cerebral artery aneurysm. For what complication is the client at risk?
A) TBI
B) Brain cancer
C) Hemorrhagic stroke
D) Embolic stroke
C) Hemorrhagic stroke
A client hospitalized for hypertension presses the call light and reports “feeling funny.” When the nurse gets to the room, the client is slurring words and has right-sided weakness. What would the nurse do first?
A) Perform a focused neurological assessment
B) Position the client in a sitting position
C) Assess airway, breathing and circulation
D) Call the primary health care provider
C) Assess airway, breathing, and circulation
The nurse is caring for a client who has a left middle cerebral artery stroke. During shift assessment, the client begins to cry unexpectedly after laughing. What would the nurse suspect that the client is experiencing?
A) Anxiety
B) Delirium
C) Emotional lability
D) Depression
C) Emotional lability
A client completed an alteplase infusion following a thrombotic stroke. What nursing action is appropriate?
A) Insert an indwelling catheter
B) Perform frequent neurological assessments
C) Notify radiology to schedule an MRI
D) Administer an anti platelet agent
B) Perform frequent neuro assessments
The nurse is teaching assistive personnel (AP) about how to communicate with an older client who has receptive aphasia. Which instruction would the nurse include?
A) Use simple short sentences and one-step commands
B) Work with the speech-language pathologist for suggestions
C) Write sentences or words on a white board for the client
D) Speak loudly to ensure that the client can hear
A) Use simple short sentences and one-step commands
A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How would the nurse help the client compensate?
A) Approach the client on the affected side
B) Place objects in the client’s field of vision
C) Encourage turning the head from side to side
D) Cover the affected eye, if possible
D) Cover the affected eye, if possible
A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client?
A) Intracranial pressure monitor
B) Mini-mental staus examination (MMSE)
C) National Institute of Health Stroke Scale (NIHSS)
D) Glasgow Coma Score (GCS)
C) National Institute of Health Stroke Scale (NIHSS)
The nurse is monitoring a client admitted with a closed traumatic brain injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately?
A) Decreased level of consciousness (LOC)
B) BP of 140/88
C) Temperature of 100F
D) Apical pulse of 90 and regular
A) Decreased LOC
The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign or symptom would the nurse be most concerned about?
A) Head laceration
B) Headache
C) Asymmetric pupils
D) Amnesia
C) Asymmetric pupils
The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?
A) Dexamethasone
B) Phenytoin
C) Hydrochlorothiazide
D) Mannitol
D) Mannitol
A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke?
A) A-V-P-U
B) F-A-S-T
C) K-I-N-D
D) P-Q-R-S-T
B) F-A-S-T
Face, Arms, Speech & Time
The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What assessment finding would the nurse expect for this client?
A) Ataxia
B) Amnesia
C) Unilateral neglect
D) Aphasia
A) Ataxia
A client has been admitted with a diagnosis of stroke. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms?
A) Quick to anger and frustration
B) Inability to discriminate words
C) Aphasia and cautiousness
D) Impulsiveness and smiling
D) Impulsiveness and smiling
RIGHT HEMISPHERE - impulsiveness and smiling
LEFT HEMISPHERE - aphasia, cautiousness, inability to discriminate words, quick to anger and frustration
A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What would the nurse suspect that the client is most likely experiencing?
A) TIA
B) Thrombotic stroke
C) Embolic stroke
D) Hemorrhagic stroke
B) Thrombotic stroke
The nurse is planning desired outcomes for rehabilitation of a client with traumatic brain injury (TBI). What is the most important outcome for this client?
A) Preventing skin breakdown
B) Preventing further injury
C) Achieving the highest level of functioning
D) Increasing cerebral perfusion
C) Achieving the highest level of functioning
A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)?
A) Place the client in the Trendelenburg position
B) Suction the client frequently and as needed
C) Maintain neutral head position
D) Assess for Grey Turner sign
C) Maintain neutral head position
The nurse is teaching a group of older adults about stroke prevention. Which risk factors for stroke would the nurse include? SATA
A) Female gender
B) High BP
C) Previous stroke or TIA
D) Smoking
E) Use of oral contraceptives
B) High BP
C) Previous stroke or TIA
D) Smoking
E) Use of oral contraceptives
The nurse is planning health teaching for a client who had a transient ischemic attack (TIA) to help prevent a major stroke. What teaching would the nurse include? SATA
A) Seek a smoking cessation program, if needed
B) Increase physical activity by exercising regularly
C) Monitor BP frequently to assess control
D) Take your prescribed anti platelet agent as prescribed
E) If diabetic, work to achieve glucose control as needed
F) Eat a heart-healthy diet everyday if possible
A) Seek a smoking cessation program, if needed
B) Increase physical activity by exercising regularly
C) Monitor BP frequently to assess control
D) Take your prescribed anti platelet agent as prescribed
E) If diabetic, work to achieve glucose control as needed
F) Eat a heart-healthy diet everyday if possible
The nurse is planning discharge teaching for a client after having a carotid angioplasty with stenting. As part of health teaching, what symptoms will the nurse teach the client and family to report to the primary health care provider? SATA
A) Dysphagia
B) Severe neck pain
C) Neck swelling
D) Mild headache
E) Hoarseness
A) Dysphagia
B) Severe neck pain
C) Neck swelling
E) Hoarseness
The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain injury. Which assessment findings indicate that the client will be declared as brain dead? SATA
A) Hypothermia
B) Absence of brainstem reflexes
C) Apnea not due to drugs or diseases
D) Irreversible loss of consciousness
E) Hypotension
B) Absence of brainstem reflexes
C) Apnea not due to drugs or diseases
D) Irreversible loss of consciousness
The nurse is caring for a client who states that her mother had “gallbladder problems” and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease?
A) Obesity
B) Birth control pills
C) Infertility
D) Advanced age
A) Obesity
A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test?
A) This test measures how inflamed your gallbladder and liver may be
B) You may eat and drink as much as you’d like before you have this test
C) You will have to lie still for some time while the camera is very close to your body
D) I need to know if you are allergic to shellfish because the contrast will be iodine-based
C) You will have to lie still for some time while the camera is very close to your body
The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse’s priority intervention when caring for this client?
A) Keeping the biliary drainage bag below the level of the catheter-insertion site
B) Checking the client’s blood glucose frequently to monitor for diabetes
C) Managing pain with continuous opioid patient-controlled analgesia (PCA)
D) Capping the catheter if it starts to leak around the insertion site
A) Keeping the biliary drainage bag below the level of the catheter-insertion site
The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy (“lap chole”). What statement by the client indicates a need for further teaching?
A) I will likely need oral pain medications for the first few days after my surgery
B) I should only be hospitalized for 2 to 3 days after my surgery
C) I will probably not be at risk for complications from this surgery
D) I should be able to go back to work in the next week or so
B) I should only be hospitalized for 2 to 3 days after my surgery
The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client?
A) Sausage and scrambled eggs
B) Steak and French fries
C) Turkey sandwich on wheat bread
D) Fried chicken and mashed potatoes
C) Turkey sandwich on wheat bread
A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse’s priority assessment at this time?
A) Respiratory assessment
B) Cardiovascular assessment
C) Abdominal assessment
D) Pain intensity assessment
A) Respiratory assessment
A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor?
A) Cirrhosis
B) Crohn’s disease
C) Peritonitis
D) Peptic ulcer disease
C) Peritonitis
The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully?
A) Blood glucose
B) Blood urea nitrogen
C) Phosphorus
D) Platelet count
A) Blood glucose
A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client?
A) Assist the client to assume a position of comfort
B) Administer opioid analgesic medication
C) Do not administer food or fluids by mouth
D) Measure intake and output every shift
B) Administer opioid analgesic medication
Pain relief is the highest priority for the client with acute pancreatitis.
Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.
A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element?
A) High fat
B) High fiber
C) Carbohydrates
D) Protein
D) Protein
The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication?
A) Take pancrelipase before meals
B) Wipe your lips after taking pancrelipase
C) Administer pancrelipase before taking an antacid
D) Chew tablets before swallowing
B) Wipe your lips after taking pancrelipase
To avoid skin irritation
A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? SATA
A) Ensure that drainage color is clear
B) Check blood glucose often
C) Place the client in the supine position
D) Check bowel sounds and stools
E) Monitor mental status
B) Check blood glucose often
D) Check bowel sounds and stools
E) Monitor mental status
The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? SATA
A) Elastase
B) Amylase
C) Glucose
D) Lipase
E) Trypsin
F) Calcium
A) Elastase
B) Amylase
C) Glucose
D) Lipase
E) Trypsin
After receiving change-of-shift report on these clients, which client does the nurse plan to assess first?
A) Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L).
B) Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain.
C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min.
D) Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography.
C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min.
Which factor or condition does the nurse expect to result in an increase in a client’s production of thyroid hormones (TH)?
A) Getting 8 hours of sleep nightly
B) Chronic constipation
C) Protein-calorie malnutrition
D) Cold environmental temperatures
D) Cold environmental temperatures
Which client assessment finding indicates to the nurse the need to assess further for a possible endocrine problem?
A) Increased appetite in a 40 y/o man who started an aerobic exercise program 1 week ago
B) Increased facial hair and absent menses in a 28-year-old nonpregnant woman
C) Male-pattern baldness in a 32-year-old man
D) Dry skin on the shins of a 70-year-old woman
B) Increased facial hair and absent menses in a 28-year-old nonpregnant woman
What is the nurse’s best first response when a client with a suspected endocrine disorder says, “I can’t, you know, satisfy my wife anymore.”?
A) “Don’t worry. It happens to everyone occasionally.”
B) “Do you use any over the counter or recreational drugs?”
C) “Can you please tell me more?”
D) “Would you like to speak with a counselor?”
C) “Can you please tell me more?”
What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been taking an oral cortisol preparation for 2 years because of a respiratory problem?
A) Decreased sodium; decreased glucose
B) Increased sodium; increased glucose
C) Increased sodium; decreased glucose
D) Decreased sodium; increased glucose
B) Increased sodium; increased glucose
Which action in the plan of care for a client who is hospitalized for pituitary function testing would be most appropriate for the nurse to delegate to an experienced assistive personnel (AP)?
A) Checking the client’s blood glucose levels every 4 hours
B) Monitoring the client’s response to the IV insulin given during a stimulation test
C) Teaching the client about a hormone suppression test
D) Assessing the client for symptoms of hypopituitarism
A) Checking the client’s blood glucose levels every 4 hours
Which laboratory finding in a client with a possible pituitary disorder will the nurse report to the health care provider immediately?
A) Blood glucose 148 mg/dL (7.4 mmol/L)
B) Blood urea nitrogen (BUN) 40 mg/dL (14.3 mmol/L)
C) Serum sodium 110 mEq/L (110 mmol/L)
D) Serum potassium 3.2 mEq/L (3.2 mmol/L)
C) Serum sodium 110 mEq/L (110 mmol/L)
Which action is most important for the nurse to perform when caring for an older client decreased antidiuretic hormone (ADH) production?
A) Inspecting feet and legs for
B) Planning for weight-bearing activities
C) Stressing the important of fiber in the diet
D) Encouraging fluids every 2 hours
D) Encouraging fluids every 2 hours
Which laboratory findings will the nurse use to validate the statement of a client with diabetes that therapy instructions for glucose control “have been followed to the letter” for the past 2 months?
A) Random blood glucose level
B) Fasting blood insulin level
C) Fasting blood glucose level
D) Glycosylated hemoglobin (HbA1c)
D) Glycosylated hemoglobin (HbA1c)
After instructing a client about the correct procedure for a 24-hour urine test, which client statement indicates to the nurse a need for further teaching?
A) “I will not eat any fatty foods when I am collecting urine for this test.”
B) “To end the collection, I must empty my bladder and add this urine to the collection.”
C) “I need to keep the urine container cool in a separate refrigerator or cooler.”
D) “I won’t save the first urine sample of the day.”
A) “I will not eat any fatty foods when I am collecting urine for this test.”
Which changes in laboratory values will the nurse expect to see in a client who has tumor causing excess secretion of aldosterone? SATA
A) Hypoglycemia
B) Hyponatremia
C) Hypokalemia
D) Hypernatremia
E) Hyperglycemia
F) Hyperkalemia
C) Hypokalemia
D) Hypernatremia
Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences?
A) Prolactin and prolactin inhibiting hormone (PIH)
B) Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH)
C) Growth hormone (GH) and melanocyte-stimulating hormone (MSH)
D) Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
B) Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH)
Which question is most relevant to ask a male client suspected to have a gonadotropin deficiency?
A) “Are you experiencing any pain during sexual intercourse?”
B) “Do you work with or have hobbies that involve exposure to chemicals?”
C) “Have you gained or lost any weight recently?”
D) “How often do you need to shave your face?”
D) “How often do you need to shave your face?”
Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective?
A) Urine output of 30 to 50 mL/hr
B) Blood glucose level of 110 mg/dL (6.1 mmol/L)
C) Respiratory rate of 20 breaths/min
D) Potassium level of 3.9 mEq/L (mmol/L)
A) Urine output of 30 to 50 mL/hr
What is the nurse’s best response when a client, who has been taking high-dose corticosteroid therapy for a month for a problem that has now resolved, asks you why she needs to continue taking the corticosteroid?
A) “Corticosteroids are a type of hormone, and once you have been started on a replacement hormone, you must continue the hormone replacement therapy for the rest of your life.”
B) “The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again.”
C) “It is possible for your health problem to recur when corticosteroid therapy is halted suddenly.”
D) “The drug suppressed your immune system while you were taking it. Slowly decreasing the dose over time prevents your immune system from starting up too quickly and causing allergic reactions.”
B) “The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again.”
What is the nurse’s best action when noticing that the phlebotomist, who plans to draw blood from the client with severe hypercortisolism, displays symptoms of a cold?
A) Ensuring the phlebotomist wears a facemask while in the client’s room
B) Asking the phlebotomist to delay the blood draw
C) Monitoring the client closely for cold-like symptoms
D) Placing a facemask on the client
A) Ensuring the phlebotomist wears a facemask while in the client’s room
For which client will the nurse question the prescription for long-term androgen therapy?
A) A 40 year old who also has syndrome of inappropriate antidiuretic hormone (SIADH).
B) A 52 year old with a history of prostate cancer treatment.
C) A 30 year old who is taking antiviral therapy for HIV disease.
D) A 66 year old with impotence that is resistant to standard erectile dysfunction therapy.
B) A 52 year old with a history of prostate cancer treatment.
Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess?
A) “Do you think if I lost weight my sleep apnea would improve?”
B) “Why do I feel thirsty all the time?”
C) “How can I make my skin less itchy?”
D) “Does everyone’s feet get bigger during menopause?”
D) “Does everyone’s feet get bigger during menopause?”
For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately?
A) Dry lips and oral mucosa on examination
B) Nasal drainage that tests negative for glucose
C) Urine specific gravity of 1.016
D) Client report of a headache and stiff neck
D) Client report of a headache and stiff neck
Which statement made by the client who is going home after a transsphenoidal hypophysectomy indicates to the nurse correct understanding of actions to prevent complications from this treatment?
A) “While I am awake, I will be sure to cough and deep breathe at least every 2 hours.”
B) “I will keep the cat food bowl on my counter so that I do not have to bend over.”
C) “Whenever I am out-of-doors in the sunshine, I will wear dark glasses.”
D) “If the dressing gets wet, I will wash the incision line and redress it immediately.”
B) “I will keep the cat food bowl on my counter so that I do not have to bend over.”
Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)?
A) Administering an infusion of 150 mL hypertonic saline over the next 3 hours
B) Drawing blood for hemoglobin and hematocrit levels
C) Measuring serial weights at the same daily with the client wearing the same amount of clothing
D) Inserting an indwelling catheter and monitoring urine output
D) Inserting an indwelling catheter and monitoring urine output
Which change in serum electrolyte values in the past 12 hours for a client with syndrome of inappropriate antidiuretic hormone (SIADH) being treated with tolvaptan will the nurse report immediately to the health care provider?
A) Serum sodium increases from 122 mEq/L to 140 mEq/L.
B) Serum potassium decreases from 4.2 mEq/L to 3.8 mEq/L.
C) Serum chloride decreases from 109 mEq/L to 99 mEq/L.
D) Serum calcium increases from 9.5 mg/dL to 10.2 mg/dL.
A) Serum sodium increases from 122 mEq/L to 140 mEq/L.
The purpose of tolvaptan is to restore a normal sodium concentration to the blood and other extracellular fluid.
Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)?
A) New-onset hypertension.
B) The client reports extreme salt craving.
C) No change in urine output with minimal fluid intake.
D) The client’s headache is gradually increasing in intensity.
C) No change in urine output with minimal fluid intake.
Which client report of changes in appearance indicates to the nurse that a client’s adrenal insufficiency is related to direct malfunction of the adrenal glands?
A) 5-lb weight loss
B) Dry, cracked lips
C) Thinning pubic hair
D) Skin darkening
D) Skin darkening
Which assessment finding in a client with hyperaldosteronism indicates to the nurse that the condition is becoming more severe?
A) Urine output for the past 24 hours has increased.
B) Client reports numbness and tingling around the mouth.
C) Temperature is now elevated.
D) pH is now 7.43.
B) Client reports numbness and tingling around the mouth.
Hyperaldosteronism causes potassium to be excreted excessively. As hypokalemia becomes more severe, paresthesias occur with numbness and tingling around the mouth and of the fingers and toes.
Alkalosis is possible, but the pH shown is normal. Temperature elevation and increased urine output are not associated with a worsening of hyperaldosteronism.
In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse instruct a client with Cushing disease to make?
A) High carbohydrate, low potassium, and fluid restriction
B) Low carbohydrate, high calorie, and low sodium
C) Low protein, high carbohydrate, and low calcium
D)High protein, high carbohydrate, and low potassium
B) Low carbohydrate, high calorie, and low sodium
What is the nurse’s best response when a client with Cushing syndrome screams at her husband, bursts into tears, throws her water pitcher against the wall, and then says “I feel like I am going crazy”?
A) “You must learn to control your behavior. Because you are disturbing others, I am going to keep the door to your room closed and restrict your visitors.”
B) You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you.”
C) “I will tell your primary health care provider order a psychiatric consult for you.”
D) “You are probably feeling this way because you are frightened about having a chronic disease. Would you like some information about a support group?”
B) You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you.”
Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. The client’s need to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. Drug therapy to reduce these feelings and behaviors may be appropriate.
The nurse has just received report on a group of clients. Which client is the nurse’s first priority?
A) A 42 year old with diabetes insipidus who has a dose of desmopressin due.
B) A 35 year old with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L).
C) A 50 year old with pituitary adenoma who is reporting a severe headache.
D) A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).
D) A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).
Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.)
A) Bending at the waist
B) Talking
C) Deep breathing
D) Coughing
E) Wearing makeup
F) Using dental floss
A) Bending at the waist
D) Coughing
For which symptoms will the nurse instruct the family and client who is being treated for diabetes insipidus (DI) to call 911 or go to the nearest emergency department? (Select all that apply.)
A) Decreased urine output
B) Hypotension
C) Weigh gain of more than 2.2 lb (1 kg) in 24 hours
D) Persistent headache
E) Hyperglycemia
F) Acute confusion
A) Decreased urine output
C) Weigh gain of more than 2.2 lb (1 kg) in 24 hours
D) Persistent headache
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?
A) Help the client identify each medication by its color
B) Provide written materials with large print size
C) Sit on the clients right side and speak into the right ear
D) Allow the client to use a white board to ask questions
C) Sit on the clients right side and speak into the right ear
A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary HCP?
A) Mild temporal headache
B) Pupils equal and react to light
C) A + O X 3
D) Decreasing level of consciousness
D) Decreasing level of consciousness
A nurse assesses a client recovering from a cerebral angiography via the right femoral artery. Which assessment would the nurse complete?
A) Palpate bilateral lower extremity pulses
B) Obtain orthostatic BP readings
C) Perform a funduscopic examination
D) Assess the gag reflex prior to eating
A) Palpate bilateral lower extremity pulses
A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client’s concern?
A) Request a prescription for an antispasmodic drug such as baclofen
B) Prepare the client for deep brain stimulation surgery
C) Refer the client to a massage therapist to relax the muscles
D) Consult with the occupational therapist for self-care assistance
A) Request a prescription for an antispasmodic drug such as baclofen
A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client’s discharge teaching?
A) Be sure that you use a wheelchair when you go out in public
B) Wear an undergarment brief at all times in case of incontinence
C) Avoid overexertion, stress, and extreme temperature if possible
D) Avoid having sexual intercourse to conserve energy
C) Avoid overexertion, stress, and extreme temperature if possible
A nurse assesses a client with a spinal cord injury at level T5. The client’s BP is 184/95 mmHg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next?
A) Initiate oxygen via a nasal cannula
B) Recheck the client’s BP
C) Palpate the bladder for distention
D) Administer a prescribed beta blocker
C) Palpate the bladder for distention
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction.
The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first?
A) Assess level of consciousness
B) Obtain vital signs
C) Administer oxygen therapy
D) Evaluate respiratory status
D) Evaluate respiratory status
A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client?
A) Quadriplegia
B) Flaccid bowel
C) Spastic bladder
D) Tetraparesis
B) Flaccid bowel
The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome?
A) Rolling walker
B) Quad cane
C) Adjustable crutches
D) Sliding board
D) Sliding board
The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client’s care?
A) Fracture
B) Malabsorption
C) Delirium
D) Anemia
A) Fracture
Older adults who have impaired mobility due to a health problem or injury are at risk for complications of immobility, such as osteoporosis (bone loss) which leads to fracture
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehab program. The client states, “I don’t understand the needs for rehab; the paralysis will not go away and it will not get better.” How would the nurse respond?
A) If you don’t want to participate in the rehabilitation program, I’ll let your primary healthcare provider know.
B) Rehabilitation programs have helped many patients with your injury. You should give it a chance
C) The rehab program will teach you how to maintain the functional ability you have and prevent further disability
D) When new discoveries are made regarding paraplegia, people in rehab programs will benefit first
C) The rehab program will teach you how to maintain the function ability you have and prevent further disability
A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching?
A) I should have a lot less pain surgery
B) I’ll be in the hospital for 2 to 3 days
C) I should not have any major surgical complications
D) I could possibly get an infection after surgery
B) I’ll be in the hospital for 2 to 3 days
Percutaneous endoscopic discectomy is a minimally invasive surgical procedure that requires a shorter hospital stay (23 hours or less) when compared to open traditional surgery. The risk for surgical complications is very low and clients experience less far pain from this procedure.
A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client’s postoperative instructions?
A) Only lift items that are 10 lbs
B) Wear your neck brace whenever you are out of bed
C) You must remain in bed for 3 weeks after surgery
D) You will be prescribed medications to prevent graft rejection
B) Wear your neck brace whenever you are OOB
A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary HCP? SATA
A) Surgical discomfort
B) Redness and itching at the incision site
C) Incisional bulging
D) Clear drainage on the dressing
E) Sudden and severe headache
C) Incisional bulging
D) Clear drainage on the dressing
E) Sudden and severe headache
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client’s hips and sacrum. What action would the nurse take? SATA
A) Apply a barrier cream to protect the skin from excoriation
B) Perform range-of-motion (ROM) exercise for the hip joint
C) Reposition the client off of the reddened areas
D) Get the client out of bed and into a chair several times a day
E) Apply a pressure-reducing mattress
C) Reposition the client off of the redness areas
E) Apply a pressure-reducing mattress
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? SATA
A) Heart rate of 34 beats/min
B) BP of 185/65 mmHg
C) Urine output less than 30 mL/hr
D) Decreased LOC
E) Increased O2 saturation
A) HR - 34 beats/min
C) Urine output less than 30 mL/hr
D) Decreased LOC
A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in the client’s plan of care? SATA
A) Remove the vest for client bathing
B) Assess the pin sites for signs of infection
C) Loosen the pins when sleeping
D) Decrease the patient’s oral fluid intake
E) Assess thickest and back for skin breakdown
B) Assess the pin sites for signs of infection
E) Assess the chest and back for skin breakdown
A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nurse to a complication from this procedure? SATA
A) Difficulty swallowing
B) Hoarse voice
C) Constipation
D) Bradycardia
E) Hypertension
A) Difficulty swallowing
B) Hoarse voice
A nurse assesses cerebrospinal fluid leaking onto a client’s surgical dressing. What actions would the nurse take? SATA
A) Place the client in a flat position
B) Monitor vital signs for hypotension
C) Utilize a bedside commode
D) Assess for abdominal distention
E) Report the leak to the surgeon
A) Place the client in a flat position
E) Report the leak to the surgeon
A client is admitted with a sudden decline in LOC. What is the nursing action at this time?
A) Assess the client for hypoglycemia and hypoxia
B) Place the client on his or her side
C) Prepare for administration of a fibrinolytic agent
D) Start a continuous IV heparin sodium infusion
A) Assess the client for hypoglycemia and hypoxia
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient’s spouse is very frusterated, stating that the patient’s personality has changed and the situation is very difficult. What response by the nurse is most appropriate?
A) Ask the client why he or she is acting out and behaving differently
B) Refer the client and spouse to a head injury support group
C) Explain that personality changes are common following brain injuries
D) Tell the spouse that this is expected and he or she will have to learn to cope
C) Explain that personality changes are common following brain injuries
The nurse is caring for 4 clients with TBIs. Which client would the nurse assess first?
A) Client with amnesia from the incident
B) Client who has a Glascow Coma Scale score of 12
C) Client with a PaCO2 of 36 mmHg and on a ventilator
D) Client who has a temperature of 102 F
D) Client who has a temperature of 102 F
A fever is a poor prognostic indicator in patients with brain injuries.
After a craniotomy, the nurse assesses the client and finds dry, sticky mucus membranes, acute confusions and restlessness. The client has IV fluids running at 75mL/hr. What action by the nurse would the nurse take first?
A) Assess the client’s urinary output
B) Assess the client’s serum sodium level
C) Increase the rate of the IV infusion
D) Provide oral care every hour
B) Assess the client’s serum sodium level
A client who had therapeutic hypothermia after a TBI is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process?
A) Cardiac dysrhythmias
B) Loss of consciousness
C) N/V
D) Fever
A) Cardiac dysrhythmias
A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client?
A) Phenytoin
B) Lorazepam
C) Mannitol
D) Morphine
C) Mannitol
A nurse cares for older clients who have TBIs. What does the nurse understand about this population? SATA
A) Admission can overwhelm the coping mechanisms for older adults
B) Alcohol is typically involved in most TBI’s for this age group
C) These clients are more susceptible to systemic and wound infections
D) Other medical conditions can complicate treatment for these clients
E) Very few traumatic brain injuries occur in this age-group
A) Admission can overwhelm the coping mechanisms for older adults
C) These clients are more susceptible to systemic and wound infections
D) Other medical conditions can complicate treatment for these clients
A nurse is discharging a client from the ED who has a mild TBI. What information obtained from the client represents a possible barrier to self-management? SATA
A) Does not want to purchase a thermometer
B) Is allergic to acetaminophen
C) Laughing, says “strenuous? whats that”
D) Lives alone and is new in town with no friends
E) Plans to have a beer and go to bed once home
B) Is allergic to acetaminophen
D) Lives alone and is new in town with no friends
E) Plans to have a beer and go to bed once home
The nurse assess a client who has a mild TBI for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? SATA
A) Sensitivity to light and sound
B) Reports feeling foggy
C) Unconscious for an hour after injury
D) Elevated temperature
E) Widened pulse pressure
A) Sensitivity to light and sound
B) Reports feeling foggy
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis?
A) Metabolic syndrome
B) Liver cancer
C) Nonalcoholic fatty liver disease
D) Hepatitis C
D) Hepatitis C
The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites?
A) Monitor intake and output
B) Provide a low-sodium diet
C) Increase oral fluid intake
D) Weigh the patient daily
B) Provide a low-sodium diet
The nurse assess a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse?
A) Urine output via indwelling urinary catheter is 20 mL/hour
B) Blood pressure increases from 110/58 to 120/62 mmHg
C) Respiratory rate decrease from 22 to 16 breaths/min
D) A decrease in the client’s weight by 3 lb (1.4 kg)
A) Urine output via indwelling catheter is 20 mL/hr
The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often?
A) African Americans
B) Asian/Pacific islanders
C) Latinos
D) French
C) Latinos
The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond?
A) A low-protein diet will help the liver rest and will restore liver function
B) Less protein in the diet will help prevent confusion associated with liver failure
C) Increasing dietary protein will help the patient gain weight and muscle mass
D) Low dietary protein is needed to prevent fluid from leaking into the abdomen
B) Less protein in the diet will help prevent confusion associated with liver failure
The nurse is caring for a client who is prescribed lactulose. The client states, “ I do not want to take this medication because it causes diarrhea.” How would the nurse respond?
A) Diarrhea is expected; that’s how your body gets rid of ammonia
B) You may take antidiarrheal medication to prevent loose stools
C) Do not take any more of the medication until your stools firm up
D) We will need to send a stool specimen to the laboratory asap
A) Diarrhea is expected; that’s how your body gets rid of ammonia
The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure?
A) Musculoskeletal
B) Neurologic
C) Mental health
D) Cardiovascular
D) Cardiovascular
A Telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states,”I’m having right belly pain and have a temperature of 101 F.” How would the nurse respond?
A) The anti-rejection drugs you are taking make you susceptible to infection
B) You should go to the hospital immediately to get checked out
C) You should take an additional dose of cyclosporine today
D) Take acetaminophen every 4 hours until you feel better
B) You should go to the hospital immediately to get checked out
After teaching a client who has alcohol-induced cirrhosis, a nurse assess the client’s understanding. What statement made by the client indicates a need further teaching?
A) I cannot drink any alcohol at all anymore
B) I should not take over-the-counter medications
C) I need to avoid protein in my diet
D) I should eat small, frequent balanced meals
C) I should avoid protein in my diet
Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing.
The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take?
A) Have the client sign the informed consent form
B) Get the patient into a chair before the procedure
C) Help the client lie flat in bed on the right side
D) Assist the client to void before the procedure
D) Assist the client to void before the procedure
The nurse is caring for a client who has cirrhosis from substance abuse. The client states, “All of my family hates me,” How would the nurse respond?
A) You should make peace with your family
B) This is not unusual, my family hates me too. (Lol)
C) I will help you identify a support system
D) You must attend alcoholics anonymous
C) I will help you identify a support system
The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? SATA
A) Infection
B) GI bleeding
C) IBS
D) Constipation
E) Anemia
F) Hypovolemia
A) Infection
B) GI bleeding
D) Constipation
F) Hypovolemia
A nurse assesses a client who has cirrhosis of the liver. Which lab findings would the nurse expect in clients with this disorder? SATA
A) Elevated aspartate transaminase
B) Elevated international normalized ratio (INR)
C) Decreased serum globulin levels
D) Decreased serum alkaline phosphatase
E) Elevated serum ammonia
F) Elevated prothrombin time (PT)
B) Elevated international normalized ratio (INR)
E) Elevated serum ammonia
F) Elevated prothrombin time (PT)
The nurse is caring for a client who has late-staged (advanced) cirrhosis. What assessment findings would the nurse expect? SATA
A) Jaundice
B) Clay-colored stools
C) Icterus
D) Ascites
E) Petechiae
F) Dark urine
A) Jaundice
B) Clay-colored stools
C) Icterus
D) Ascites
E) Petechiae
F) Dark urine
A client is scheduled for a hepatobiliary imilodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test?
A) You’ll have to drink a contrast medium right before the test
B) You’ll need to do a bowel prep the night before the test
C) You’ll be able to drink liquids up until the test begins
D) You’ll have a large camera close to you during the test
D) You’ll have a large camera close to you during the test
A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client?
A) Cap the catheter drain at night to prevent leakage and skin damage
B) Position the drainage bag lower than the catheter insertion site
C) Irrigate the catheter with an ounce of saline every night
D) Pierce a hole in the top of the drainage bag to get rid of odors
B) Position the drainage bag lower than the catheter insertion site
After teaching a client who has a history of cholelithiasis, the nurse assesses the client’s understanding. Which menu selection indicates the client understands the dietary teaching?
A) Lasagna, tossed salad with Italian dressing and low-fat milk
B) Grilled cheese sandwich, tomato soup, and coffee with cream
C) Cream of potato soup, caesar salad with chicken, and a diet cola
D) Roasted chicken breast, baked potato with chives and orange juice
D) Roasted chicken breast, baked potato with chives and orange juice
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?
A) N/V
B) Severe boring abdominal pain
C) Jaundiced and itching
D) Elevated temperature
B) Severe boring abdominal pain
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client’s understanding. Which statement by the client indicates a need for further teaching?
A) The capsules can be opened and the powder sprinkled on applesauce if needed
B) I will wipe my lips carefully after I drink the enzyme preparation
C) The best time to take the enzymes is immediately after I have a meal or a snack
D) I will not mix the enzyme powder with foods or liquids that contain protein
C) The best time to take the enzymes is immediately after I have a meal or a snack
The enzymes must be taken immediately BEFORE eating meals or snacks.
The nurse documents the vital signs of a client diagnosed with acute pancreatitis:
Apical pulse = 116 beats/min
Blood pressure = 92/50
BP = 92/50
What complication of acute pancreatitis would the nurse suspect that the client might have?
A) Electrolyte imbalance
B) Pleural effusion
C) Internal bleeding
D) Pancreatic pseudocyst
C) Internal bleeding
The client is exhibiting signs of hypovolemia most likely due internal bleeding or hemorrhage.
A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess?
A) Urinary tract infection
B) Chronic kidney disease
C) Heart failure
D) Fluid and electrolyte imbalances
D) Fluid and electrolyte imbalances
Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances.
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute?
A) Temp of 100.1
B) Positive murphy sign
C) Clay-colored sools
D) Upper abdominal pain after eating
C) Clay-colored stools
Jaundice, clay-colored stools and dark urine are more commonly seen with chronic.
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary HCP?
A) Drainage from a fistula
B) Diminished bowel sounds
C) Pain at the incision site
D) Nasogastric (NG) tube drainage
A) Drainage from a fistula
Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis.
The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take?
A) Clamp the nasogastric tube
B) Place the patient in a semi-fowler position
C) Assess vital signs once every shift
D) Provide oral rehydration
B) Place the patient in semi-fowler position
A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert the nurse to a complication from this surgery?
A) Clay-colored stools
B) Substernal chest pain
C) Shortness of breath
D) Lack of bowel sounds of flatus
E) Urine output of 20 mL/6 hours
B) Substernal chest pain
C) Shortness of breath
D) Lack of bowel sounds of flatus
E) Urine output of 20 mL/6 hours
The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? SATA
A) Avoid alcohol ingestion
B) Be sure and balance rest with activity
C) Avoid caffeinated beverages
D) Avoid green, leafy vegetables
E) Eat small meals and high-calorie snacks
A) Avoid alcohol ingestion
B) Be sure and balance rest with activity
C) Avoid caffeinated beverages
E) Eat small meals and high-calorie snacks
The nurse assesses a client who is scheduled to have a lab test to determine if the client’s adrenal glands are hypoactive. What type of testing would the client likely have?
A) Catecholamine testing
B) Suppression testing
C) Bone marrow testing
D) Provocative testing
D) Provocative testing
Provocative testing is done to determine if an endocrine gland is capable of producing its normal level of hormone(s), especially when a client is suspected of having a hypoactive endocrine gland
The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition?
A) Sodium
B) Magnesium
C) Aldosterone
D) Renin
C) Aldosterone
The nurse reviews the function of thyroid gland hormones. What is the primary function of calcitonin?
A) Sodium and potassium balance
B) Magnesium balance
C) Norepinephrine balance
D) Calcium and phosphorus balance
D) Calcium and phosphorus balance
A nurse cares for a client with a hypo functioning anterior pituitary gland. Which hormones would the nurse expect to be decreased as a result? SATA
A) Thyroid-stimulating hormone
B) Vasopressin
C) Follicle-stimulating hormone
D) Calcitonin
E) Growth hormone
A) Thyroid-stimulating hormone
C) Follicle-stimulating hormone
E) Growth hormone
When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? SATA
A) Lethargy
B) Diarrhea
C) Low body temperature
D) Tachycardia
E) Slowed speech
F) Weight gain
A) Lethargy
C) Low body temperature
E) Slowed speech
F) Weight gain
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone?
A) A 36-year-old female who has used oral contraceptives for 5 years
B) A 42-year-old male who experienced head trauma 3 years ago
C) A 55-year-old female with severe allergy to shellfish and iodine
D) A 64-year-old male with adult-onset diabetes mellitus
B) A 42-year-old male who experienced head trauma 3 year ago
Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction
A nurse plans care for a client with a growth hormone deficiency. Which action would the nurse include in this client’s plan of care?
A) Avoid intramuscular medication
B) Place the client in protective isolation
C) Use a lift sheet to reposition the patient
D) Assist the client to dangle before rising
C) Use a lift sheet to reposition the client
The nurse is caring for client who has acromegaly. What physical change would the nurse expect to observe?
A) Large hands and face
B) Thin, dry skin
C) Short height
D) Truncal obesity
A) Large hands and face
The client who has acromegaly has an excess of growth hormone as an adult and therefore has a large musculoskeletal structure that is readily observed.
After teaching a client with acromegaly who is scheduled for an open transphenoidal hypophysectomy, the nurse assess the client’s understanding. Which statement made by the client indicates a need for further teaching?
A) I will no longer need to limit my fluid intake after surgery
B) I am glad no visible incision will result from this surgery
C) I hope I can go back to wearing size 8 shoes instead of size 12
D) I will wear slip-on shoes after surgery to limit bending over
C) I hope I can go back to wearing size 8 shoes instead of size 12
After teaching a client who is recovering from an endoscopic transphenoidal hypophysectomy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
A) I will wear dark glasses to prevent sun exposure
B) I’ll keep food on upper shelves so I do not have to bend over
C) I must wash the incision with saline and redress it daily
D) I should cough and deep breathe every 2 hours while I’m awake
B) I’ll keep food on upper shelves so I don’t have to bend over
A nurse cares for a client who possible has syndrome of inappropriate antidiuretic hormone (SIADH). The client’s serum sodium level is 114 mEq/L (114 mmol/L). What nursing action would be appropriate?
A) Consult with the dietitian about increased dietary sodium
B) Restrict the client’s fluid intake to 600 mL/day
C) Handle the client gently by using turn sheets for repositioning
D) Instruct assistive personnel to measure intake and output
B) Restrict the client’s fluid intake to 600mL/day
With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hours.
The nurse is caring for client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor?
A) Hypertension
B) Bradycardia
C) Dehydration
D) Pulmonary embolism
C) Dehydration
The client who has DI has fluid loss through excessive urination. Decreased fluid volume, or dehydration is manifested by tachycardia, hypotension, and possible elevated temperature.
The client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy?
A) The need to check the client’s urinary specific gravity
B) The need to take BP at least twice a day
C) The need to monitor blood glucose everyday
D) The need to weight everyday and report weight gain
D) The need to weight every day and report weight gain
A nurse cares for a client with adrenal hyper function. The client screams at her husband, bursts into tear, and throws her water pitcher against the wall. She then tells the nurse, “I feel like I am going crazy.” How would the nurse respond?
A) I will ask your doctor to order a mental health consult for you
B) You feel this way because of your hormone levels
C) Can I bring you information about support groups
D) I will close the door to your room and restrict visitors
B) You feel this way because of your hormone levels
A nurse is reviewing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with assistive personnel. What statement by the AP indicates understanding of this client’s care?
A) I will weigh the client carefully before breakfast and compare with yesterday’s weight
B) I will encourage plenty of fluids to promote urination and prevent dehydration
C) I will teach the client not to select high-sodium or salty foods on the menu
D) I will assess the client’s mucus membranes and skin for signs of dehydration
A) I will weigh the client carefully before breakfast and compare with yesterday’s weight
The nurse is caring for a client with adrenal insufficiency. What priority physical assessment would the nurse perform?
A) Respiratory
B) Skin
C) Neurologic
D) Cardiac
D) Cardiac assessment
The client who has adrenal insufficiency has hyperkalemia that can cause cardiac dysrhythmias
A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment findings would the nurse expect? SATA
A) Hypotension
B) Increased urinary output
C) Concentrated urine
D) Decreased thirst
E) Poor skin turgor
F) Bradycardia
A) Hypotension
B) Increased urinary output
E) Poor skin turgor
A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values would the nurse associate with this disorder? SATA
A) Na: 150 mEq/L
B) Na: 130 mEq/L
C) Potassium: 2.5 mEq/L
D) Potassium: 5.0 mEq/L
E) pH: 7.28
F) pH: 7.50
A) Na: 150 mEq/L
C) Potassium: 2.5 mEq/L
E) pH: 7.28
A nurse teaches a client with Cushing’s disease. Which dietary requirements would the nurse include in this client’s health teaching? SATA
A) Low calcium
B) Low carbohydrates
C) Low protein
D) Low calories
E) Low sodium
B) Low carbohydrates
D) Low calories
E) Low sodium
A nurse assesses a client with Cushing’s disease. Which assessment findings would the nurse expect? SATA
A) Moon face
B) Weight loss
C) Hypotension
D) Petechiae
E) Muscle atrophy
A) Moon face
D) Petechiae
E) Muscle atrophy
