Board Exam Nursing Test IV NLE (Practice Mode)

1. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to:

Lubricate the joint.

Prevent ankylosis of the joint.

Reduce inflammation.

Provide physiotherapy.

Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.

Explanation

Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.

2. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?

Compact bone is stronger than cancellous bone because of its greater size.

Compact bone is stronger than cancellous bone because of its greater weight.

Compact bone is stronger than cancellous bone because of its greater volume.

Compact bone is stronger than cancellous bone because of its greater density.

The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.

Explanation

The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.

3. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :

Greater the blood viscosity.

Higher the blood pH.

Less it contributes to immunity.

Lower the hematocrit.

Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.

Explanation

Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.

4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?

Visual hallucinations.

Receptive aphasia.

Hemiparesis.

Personality changes.

The occipital lobe is involve with visual interpretation.

Explanation

The occipital lobe is involve with visual interpretation.

5. An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that:

Ordered PRN analgesics are administered on a scheduled basis.

Patient controlled analgesia is avoided in this population.

Pain medication is ordered via the intramuscular route.

An order for meperidine (Demerol) is secured for pain relief.

Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.

Explanation

Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.

6. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?

Call the cardiac arrest team to alert them

Call the laboratory and repeat the test

Take the client’s vital signs and notify the physician

Obtain an ECG strip and have lidocaine available

Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac dysrhythmias.

Explanation

Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac dysrhythmias.

7. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:

Muscle strength

Symptoms

Blood pressure

Consciousness

Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.

Explanation

Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.

8. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of:

Continuity of the mucous membrane.

Inadequate fluid intake.

The length of the urethra.

Poor hygienic practices.

The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.

Explanation

The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.

9. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to:

Aid in controlling involuntary muscle movements.

Relieve pressure on weight-bearing joints.

Maintain balance and improve stability.

Prevent further injury to weakened muscles.

Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.

Explanation

Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.

10. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:

Increasing the number of tablets if dizziness or hypertension occurs.

Limiting the number of tablets to 4 per day.

Making certain the medication is stored in a dark container.

Discontinuing the medication if a headache develops.

Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.

Explanation

Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.

11. Which of the following is the most important electrolyte of intracellular fluid?

Potassium

Sodium

Chloride

Calcium

The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.

Explanation

The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.

12. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?

Heavy consumption of alcohol.

Frequent gum chewing.

Nail biting.

Poor dental habits.

Heavy alcohol ingestion predisposes an individual to the development of oral cancer.

Explanation

Heavy alcohol ingestion predisposes an individual to the development of oral cancer.

13. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;

Have arterial blood gases performed again to check for accuracy.

Increase the oxygen flow rate.

Notify the physician.

Decrease the tension of oxygen in the plasma.

This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.

Explanation

This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.

14. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?

The surgery will temporarily decrease the client’s sexual impulses.

Sexual relationships must be curtailed for several weeks.

The partner should be told about the surgery before any sexual activity.

The client will be able to resume normal sexual relationships.

Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.

Explanation

Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.

15. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct?

Strain urine for crystals and stones

Increase fluid intake.

Stop the drug if the urinary output increases

Maintain the exact time schedule for drug taking.

To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.

Explanation

To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.

16. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:

Bone marrow

Liver

Lymph nodes

Blood

Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.

Explanation

Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.

17. An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response?

“You sound concerned; You’ll probably remember more as you wake up.”

“Tell me what you think happened.”

“You were in a car accident this morning.”

“An amputation of your right leg was necessary because of an accident.”

This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.

Explanation

This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.

18. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:

Adverse effects of spironolactone (Aldactone)

Adverse effects of digoxin (Lanoxin)

Therapeutic effects of propranolol (Indiral)

Therapeutic effects of furosemide (Lasix)

Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.

Explanation

Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.

19. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

A low pH and bicarbonate level are consistent with metabolic acidosis.

Explanation

A low pH and bicarbonate level are consistent with metabolic acidosis.

20. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s:

Arterial blood pH

Pulse rate

Serum glucose

Intake and output

DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.

Explanation

DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.

21. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:

May be a forerunner of hemorrhage.

Are related to diaphoresis and possible chilling.

May indicate cerebral edema.

Increase the cardiac output.

The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.

Explanation

The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.

22. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?

Hematuria

Dysuria

Polyuria

Dribbling

Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.

Explanation

Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.

23. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:

Furosemide (Lasix)

Hydrochlorothiazide (HydroDIURIL)

Metolazone (Zaroxolyn)

Spironolactone (Aldactone)

Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.

Explanation

Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.

24. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for:

Palpitation

Visual disturbance

Decreased pulse rate

Lethargy

Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.

Explanation

Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.

25. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:

The triglycerides

The INR

Chest pain

Blood pressure

Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.

Explanation

Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.

26. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:

Swelling of the ankles increases.

Blood appears in the urine.

Increased transient Ischemic attacks occur.

The ability to concentrate diminishes.

Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.

Explanation

Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.

27. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary?

“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”

“I’m going to have a figure like a model in about a year.”

“I need to eat more high-protein foods.”

“I will be going to be out of bed and sitting in a chair the first day after surgery.”.

Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.

Explanation

Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.

28. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow:

Return of cortisone production by the adrenal glands.

Production of antibodies by the immune system

Building of glycogen and protein stores in liver and muscle

Time to observe for return of increases intracranial pressure

Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.

Explanation

Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.

29. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:

Androgens

Glucocorticoids

Mineralocorticoids

Estrogen

Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.

Explanation

Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.

30. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?

Learn to type using your left hand only.

Avoid typing in a long period of time.

Avoid carrying heavy things using the right hand.

Do manual stretching exercise during breaks.

Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.

Explanation

Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.

31. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?

“This is only a problem for women.”

“You are not at risk because of your small frame.”

“You might think about having a bone density test,”

“Exercise is a good way to prevent this problem.”

Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.

Explanation

Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.

32. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to:

Use strict sterile technique

Use exactly 100mL of fluid to mix the medication

Change the needle just before adding the medication

Rotate the bag after adding the medication

Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.

Explanation

Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.

33. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?

Take the drug with an antacid.

Lie down after meals.

Avoid dairy products in diet.

Change positions slowly.

Changing positions slowly will help prevent the side effect of orthostatic hypotension.

Explanation

Changing positions slowly will help prevent the side effect of orthostatic hypotension.

34. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states:

“I will contact the physician immediately if I develop blurred vision.”

“I will contact the physician immediately if I develop urinary retention.”

“I will contact the physician immediately if I develop swallowing difficulty.”

“I will contact the physician immediately if I develop feelings of irritability.”

Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.

Explanation

Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.

35. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by:

The presence of dry skin

A change in body weight

An altered general appearance

A decrease in blood pressure

Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.

Explanation

Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.

36. Which of the following client has a high risk for developing hyperkalemia?

Crohn’s disease

End-Stage renal disease

Cushing’s syndrome

Chronic heart failure

The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.

Explanation

The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.

37. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:

Levodopa is inadequately absorbed if given with meals.

Levodopa may cause the side effects of orthostatic hypotension.

Levodopa must be monitored by weekly laboratory tests.

Levodopa causes an initial euphoria followed by depression.

Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.

Explanation

Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.

38. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:

Urinary tract infection.

Fluid and electrolyte imbalance.

Dehydration.

Skin breakdown.

Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.

Explanation

Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.

39. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:

Inspired air will move from the lung into the pleural space.

There is greater negative pressure within the chest cavity.

The heart and great vessels shift to the affected side.

The other lung will collapse if not treated immediately.

As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.

Explanation

As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.

40. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is:

Replacement of excessive losses

Treatment of hyperpnea

Prevention of flaccid paralysis

Treatment of cardiac dysrhythmias

Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.

Explanation

Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.

41. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should:

Advise the client to refrain from vigorous brushing of teeth and hair.

Instruct the client to avoid driving for 2 weeks.

Encourage eye exercises to strengthen the ocular musculature.

Teach the client coughing and deep-breathing techniques.

Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.

Explanation

Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.

42. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:

After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.

Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.

With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.

Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.

There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.

Explanation

There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.

43. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s:

Reaction to hypertensive medications.

Denial of illness.

Response to cerebral anoxia.

Fear of the health problem.

Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.

Explanation

Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.

44. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:.

Perform quadriceps muscle setting exercises twice a day.

Sit in a chair for 30 minutes three times a day.

Lie on the abdomen 30 minutes every four hours.

Turn from side to side every 2 hours.

The hips are in extension when the client is prone; this keeps the hips from flexing.

Explanation

The hips are in extension when the client is prone; this keeps the hips from flexing.

45. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to:

Ablate the cells of the thyroid gland that produce T4.

Decrease the total basal metabolic rate.

Decrease the size and vascularity of the thyroid.

Maintain function of the parathyroid gland.

Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.

Explanation

Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.

46. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately?

Skin rash, diarrhea, and diplopia

Development of tetaniy with muscles spasms

Extreme muscle weakness and tachycardia

Nausea, vomiting, and leg and stomach cramps.

Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.

Explanation

Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.

47. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:

Catecholamines released at the site of the infarction causes intermittent localized pain.

Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.

Constriction of central and peripheral blood vessels causes a decrease in blood pressure.

Inflammation in the myocardium causes a rise in the systemic body temperature.

Temperature may increase within the first 24 hours and persist as long as a week.

Explanation

Temperature may increase within the first 24 hours and persist as long as a week.

48. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:

Increase amounts of angiotensin II to raise the client’s blood pressure.

Control excessive loss of potassium salts.

Prevent hypoglycemia and permit the client to respond to stress.

Decrease cardiac dysrhythmias and dyspnea.

Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.

Explanation

Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.

49. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:

Seizure activity

Liver function

Cardiac output

Pain relief

Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.

Explanation

Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.

50. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have:

Overgrowth of the epithelial auditory lining.

Copious, moist cerumen.

Difficulty hearing women’s voices.

Tears in the tympanic membrane.

Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.

Explanation

Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.