Nursing Practice IV care Of Clients Physiologic And Psychosocial Alterations

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      Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

    • Calcium and sodium
    • Calcium and phosphorous
    • Phosphorous and potassium
    • Potassium and sodium
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Nursing Practice IV care Of Clients Physiologic And Psychosocial Alterations - Quiz

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  • 2. 

    Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

    • Eliminate foods high in cellulose.

    • Decrease fluid intake at meal times.

    • Avoid foods that in the past caused flatus.

    • Adhere to a bland diet prior to social events.

    Correct Answer
    A. Avoid foods that in the past caused flatus.
    Explanation
    Foods that bothered a person preoperatively will continue to do so after a colostomy.

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  • 3. 

    The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is

    • Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

    • Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.

    • Oxygen is administered best using a non-rebreathing mask

    • Blood gases are monitored using a pulse oximeter.

    Correct Answer
    A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
    Explanation
    COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.

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  • 4. 

    Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?

    • Lying on the right side with legs straight

    • Lying on the left side with knees bent

    • Prone with the torso elevated

    • Bent over with hands touching the floor

    Correct Answer
    A. Lying on the left side with knees bent
    Explanation
    For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.

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  • 5. 

    Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?

    • Influenza

    • Sickle cell anemia

    • Leukemia

    • Hodgkin’s disease

    Correct Answer
    A. Hodgkin’s disease
    Explanation
    Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.

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  • 6. 

    A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?

    • Bronchitis

    • Pneumonia

    • Pneumothorax

    • Tuberculosis (TB)

    Correct Answer
    A. Pneumothorax
    Explanation
    From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.

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  • 7. 

    Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

    • “Stacy looks very nice wearing a hat”.

    • “You should not worry about her hair, just be glad that she is alive”.

    • “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.

    • “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.

    Correct Answer
    A. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.
    Explanation
    This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.

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  • 8. 

    Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

    • Face and neck

    • Right upper arm and penis

    • Right thigh and penis

    • Upper trunk

    Correct Answer
    A. Upper trunk
    Explanation
    The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.

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  • 9. 

    Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?

    • To prevent confusion

    • To prevent seizures

    • To prevent cerebrospinal fluid (CSF) leakage

    • To prevent cardiac arrhythmias

    Correct Answer
    A. To prevent cerebrospinal fluid (CSF) leakage
    Explanation
    The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.

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  • 10. 

    Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

    • It dilates peripheral blood vessels.

    • It decreases sympathetic cardioacceleration.

    • It inhibits the angiotensin-coverting enzymes

    • It inhibits reabsorption of sodium and water in the loop of Henle.

    Correct Answer
    A. It inhibits reabsorption of sodium and water in the loop of Henle.
    Explanation
    Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.

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  • 11. 

    Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

    • Reactive pupils

    • A depressed fontanel

    • Bleeding from ears

    • An elevated temperature

    Correct Answer
    A. Bleeding from ears
    Explanation
    The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.

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  • 12. 

    Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?

    • “I should contact the physician if Stacy has difficulty in sleeping”.

    • “I will call my doctor if Stacy has persistent vomiting and diarrhea”.

    • “My physician should be called if Stacy is irritable and unhappy”.

    • “Should Stacy have continued hair loss, I need to call the doctor”.

    Correct Answer
    A. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
    Explanation
    Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.

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  • 13. 

      Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NpH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

    • "Inject insulin into healthy tissue with large blood vessels and nerves."

    • "Rotate injection sites within the same anatomic region, not among different regions."

    • "Administer insulin into areas of scar tissue or hypotrophy whenever possible."

    • "Administer insulin into sites above muscles that you plan to exercise heavily later that day."

    Correct Answer
    A. "Rotate injection sites within the same anatomic region, not among different regions."
    Explanation
    The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

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  • 14. 

    Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

    • Turn him frequently.

    • Perform passive range-of-motion (ROM) exercises.

    • Reduce the client's fluid intake.

    • Encourage the client to use a footboard.

    Correct Answer
    A. Turn him frequently.
    Explanation
    The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

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  • 15. 

    Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?

    • 18

    • 21

    • 35

    • 40

    Correct Answer
    A. 21
    Explanation
    3000 x 10 divided by 24 x 60.

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  • 16. 

    The term “pink puffer” refers to the female client with which of the following conditions?

    • Adult respiratory distress syndrome (ARDS)

    • Asthma

    • Chronic obstructive bronchitis

    • Emphysema

    Correct Answer
    A. Emphysema
    Explanation
    Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

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  • 17. 

    Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:

    • Increased pH with decreased hydrogen ions.

    • Increased serum levels of potassium, magnesium, and calcium.

    • Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.

    • Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

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

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  • 18. 

    Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:

    • Notify the physician

    • Flush the IV line with saline solution

    • Immediately discontinue the infusion

    • Apply an ice pack to the site, followed by warm compress.

    Correct Answer
    A. Immediately discontinue the infusion
    Explanation
    Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.

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  • 19. 

    Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

    • Impaired clotting mechanism

    • Varix formation

    • Inadequate nutrition

    • Trauma of invasive procedure

    Correct Answer
    A. Impaired clotting mechanism
    Explanation
    Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.

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  • 20. 

    Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

    • 1.2 ml

    • 2.4 ml

    • 3.5 ml

    • 4.2 ml

    Correct Answer
    A. 2.4 ml
    Explanation
    .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.

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  • 21. 

    Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:

    • Ascites

    • Nystagmus

    • Leukopenia

    • Polycythemia

    Correct Answer
    A. Leukopenia
    Explanation
    Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

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  • 22. 

    Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position:

    • Reduce incisional pain.

    • Facilitate ventilation of the left lung.

    • Equalize pressure in the pleural space.

    • Increase venous return

    Correct Answer
    A. Facilitate ventilation of the left lung.
    Explanation
    Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.

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  • 23. 

    Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

    • 18 gtt/min

    • 28 gtt/min

    • 32 gtt/min

    • 36 gtt/min

    Correct Answer
    A. 28 gtt/min
    Explanation
    This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

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  • 24. 

    Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

    • Increased urine output

    • Altered level of consciousness

    • Decreased tendon reflex

    • Hypotension

    Correct Answer
    A. Altered level of consciousness
    Explanation
    Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.

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  • 25. 

     The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:

    • Anaphylactic shock

    • Cardiogenic shock

    • Distributive shock

    • Myocardial infarction (MI)

    Correct Answer
    A. Cardiogenic shock
    Explanation
    Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock.

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  • 26. 

    JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

    • Replaces estrogen

    • Decreases infection

    • Decreases inflammation

    • Decreases bone demineralization

    Correct Answer
    A. Decreases inflammation
    Explanation
    Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.

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  • 27. 

    Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

    • Administer Kayexalate

    • Restrict foods high in protein

    • Increase oral intake of cheese and milk.

    • Administer large amounts of normal saline via I.V.

    Correct Answer
    A. Administer Kayexalate
    Explanation
    Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.

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  • 28. 

    A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?

    • Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels

    • Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.

    • Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.

    • Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel

    Correct Answer
    A. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.
    Explanation
    An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.

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  • 29. 

      Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?

    • Metabolic acidosis

    • Metabolic alkalosis

    • Respiratory acidosis

    • Respiratory alkalosis

    Correct Answer
    A. Respiratory acidosis
    Explanation
    Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.

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  • 30. 

    Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Which laboratory test indicates liver cirrhosis?

    • Decreased red blood cell count

    • Decreased serum acid phosphate level

    • Elevated white blood cell count

    • Elevated serum aminotransferase

    Correct Answer
    A. Elevated serum aminotransferase
    Explanation
    Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.

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  • 31. 

    The term “blue bloater” refers to a male client which of the following conditions?

    • Adult respiratory distress syndrome (ARDS)

    • Asthma

    • Chronic obstructive bronchitis

    • Emphysema

    Correct Answer
    A. Chronic obstructive bronchitis
    Explanation
    Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.

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  • 32. 

    Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

    • Take the pulse rate once a day, in the morning upon awakening

    • May be allowed to use electrical appliances

    • Have regular follow up care

    • May engage in contact sports

    Correct Answer
    A. May engage in contact sports
    Explanation
    The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

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  • 33. 

    During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

    • Squamous cell carcinoma

    • Multiple myeloma

    • Leukemia

    • Kaposi's sarcoma

    Correct Answer
    A. Kaposi's sarcoma
    Explanation
    Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.

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  • 34. 

    Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:

    • Lie on my left side while instilling the irrigating solution.”

    • Keep the irrigating container less than 18 inches above the stoma.”

    • Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”

    • Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”

    Correct Answer
    A. Keep the irrigating container less than 18 inches above the stoma.”
    Explanation
    This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.

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  • 35. 

    After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

    • Call for help.

    • Obtain vital signs

    • Ask the client to “lift up”

    • Apply gloves and assess the groin site

    Correct Answer
    A. Apply gloves and assess the groin site
    Explanation
    Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

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  • 36. 

    A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?

    • Kidneys’ excretion to sodium only.

    • Kidneys’ retention of sodium and water

    • Kidneys’ excretion of sodium and water

    • Kidneys’ retention of sodium and excretion of water

    Correct Answer
    A. Kidneys’ excretion of sodium and water
    Explanation
    The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.

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  • 37. 

    For a client with Graves' disease, which nursing intervention promotes comfort?

    • Restricting intake of oral fluids

    • Placing extra blankets on the client's bed

    • Limiting intake of high-carbohydrate foods

    • Maintaining room temperature in the low-normal range

    Correct Answer
    A. Maintaining room temperature in the low-normal range
    Explanation
    Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

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  • 38. 

    Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?

    • Adult respiratory distress syndrome (ARDS)

    • Atelectasis

    • Bronchitis

    • Pneumonia

    Correct Answer
    A. Adult respiratory distress syndrome (ARDS)
    Explanation
    Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.

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  • 39. 

    Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the   nurse that the teaching was successful?

    • “I will wear the stockings until the physician tells me to remove them.”

    • “I should wear the stockings even when I am sleep.”

    • “Every four hours I should remove the stockings for a half hour.”

    • “I should put on the stockings before getting out of bed in the morning.”

    Correct Answer
    A. “I should put on the stockings before getting out of bed in the morning.”
    Explanation
    Promote venous return by applying external pressure on veins.

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  • 40. 

    Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

    • This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

    • The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.

    • The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.

    • The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.

    Correct Answer
    A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
    Explanation
    Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

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  • 41. 

    Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:

    • Beta -adrenergic blockers

    • Calcium channel blocker

    • Narcotics

    • Nitrates

    Correct Answer
    A. Beta -adrenergic blockers
    Explanation
    Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by
    decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload).

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  • 42. 

    After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?

    • Air leak

    • Adequate suction

    • Inadequate suction

    • Kinked chest tube

    Correct Answer
    A. Air leak
    Explanation
    Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.

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  • 43. 

      A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?

    • Asthma attack

    • Atelectasis

    • Bronchitis

    • Fat embolism

    Correct Answer
    A. Fat embolism
    Explanation
    Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.

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  • 44. 

    A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

    • Acute asthma

    • Chronic bronchitis

    • Pneumonia

    • Spontaneous pneumothorax

    Correct Answer
    A. Spontaneous pneumothorax
    Explanation
    A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

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  • 45. 

    Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

    • Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.

    • Urine output of 20 ml/hour.

    • White pulmonary secretions.

    • Rectal temperature of 100.6° F (38° C).

    Correct Answer
    A. Urine output of 20 ml/hour.
    Explanation
    A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit.

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  • 46. 

    If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

    • The space remains filled with air only

    • The surgeon fills the space with a gel

    • Serous fluids fills the space and consolidates the region

    • The tissue from the other lung grows over to the other side

    Correct Answer
    A. Serous fluids fills the space and consolidates the region
    Explanation
    Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled.

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  • 47. 

    Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?

    • Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin.

    • Increase in the number of normal cells in a normal arrangement in a tissue or an organ.

    • Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found.

    • Alteration in the size, shape, and organization of differentiated cells.

    Correct Answer
    A. Alteration in the size, shape, and organization of differentiated cells.
    Explanation
    Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

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  • 48. 

    Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

    • High corticotropin and low cortisol levels

    • Low corticotropin and high cortisol levels

    • High corticotropin and high cortisol levels

    • Low corticotropin and low cortisol levels

    Correct Answer
    A. High corticotropin and high cortisol levels
    Explanation
    A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.

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  • 49. 

    A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

    • Auscultate bowel sounds.

    • Palpate the abdomen.

    • Change the client's position.

    • Insert a rectal tube.

    Correct Answer
    A. Auscultate bowel sounds.
    Explanation
    If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

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  • Mar 22, 2023
    Quiz Edited by
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  • Jul 12, 2010
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