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Medical Surgical Nursing Review Series 1. The client in chronic renal failure has a serum potassium level of 5.

2 mEq/L. Which of the following would nurse do next? a. Prepare to administer IV potassium b. Notify the physician immediately c. Prepare to administer ion exchange resin d. Continue to monitor client D: The clients potassium level is normal. Therefore, the nurse would monitor the client. 2. When discussing anticholinesterase agents with the client diagnosed with myasthenia gravis, the nurse would include which of the following instructions? a. Taking the medication on an empty stomach to increase absorption b. Ensuring for available bathroom facilities due to increased urinary frequency c. Obtaining serum drug levels every 3 months d. Taking the drug 30 minutes before activities to obtain peak effects D: Anticholinesterase agents inhibit breakdown of acetylcholine at the neuromuscular junction. Taking the medication 30 minutes before activities allows the drug to reach its peak effect, thereby increasing the clients muscle strength. 3. Nursing interventions for the client experiencing pruritus would include which of the following? a. Instructing the client to wear extra clothing b. Washing skin with antibacterial soap and water c. Maintaining a warm room temperature d. Instructing the client to keep rooms humidified D: Clients with pruritus need moisture in the environment to reduce the drying effects and subsequent itching. Therefore, keeping the rooms humidified helps to reduce the itch. 4. Which of the following laboratory tests would provide the most specific indication that a client has suffered a myocardial infarction? a. Creatine kinase BB

b. Lactic dehydrogenase c. Creatine kinase MB d. Myoglobin C: Creatine kinase MB, a cardiac specific isoenzyme, is found only in cardiac tissue and rises only when cardiac injury has occurred. This isoenzyme starts to increase within 1 hour, peaking 24 hours of MI. 5. Which of the following must the nurse keep in mind when administering oxygen to a client with a chronic obstructive pulmonary disease (COPD)? a. A facemask is necessary for delivery of adequate concentrations b. The oxygen must be administered at a low rate c. The client is encouraged to remove the oxygen as often as possible d. Oxygen is reserved for use when the client is short of breath. B: The primary stimulus to breathe for the client with COPD is the elevated carbon dioxide levels. If oxygen were administered at too high a rate, then the clients respiratory drive would be depressed. 6. The client demonstrates self-management of low blood glucose reactions when stating which of the following? a. If I take one lifesaver to reverse my low blood sugar, then I will be fine. b. I will drink 4 to 6 ounces of fruit juice and then check my blood sugar. c. I will need to ask my doctor for a HgA1C test. d. Ill hold my next dose of insulin if my glucose level is >200 mg/dL. B: Four to six ounces of fruit juice provides the client with approximately 15 gm of carbohydrate, the amount the needed to correct a low blood sugar. 7. A parent makes all of the following comments about her young child to the nurse. Which comment would indicate to the nurse that the child may have Rocky Mountain spotted fever? a. The high fever started 3 days ago when we returned from a camping trip and now there is a rash. b. There are creamy, white, curdlike patches in the mouth and on the tongue and I cant get them out. c. It is so hard to swallow. There must be an obstruction somewhere in the childs throat.

d. First there was a dry cough, and then 2 days ago a sore throat started. Now there is some difficulty breathing. A: Rocky Mountain spotted fever is a potentially infectious disease marked by fever and skin rash. The clue in the patients statement is the recent return from a camping trip. The infection is usually transmitted by dog, wood, or tick. 8. For the client with chronic renal failure (CRF), which of the following dietary modification instructions would be included in the clients plan of care? a. Protein restricted to 1 g/kg ideal body weight. b. Increase in foods containing potassium and sodium c. Foods primarily consisting of complete amino acids d. Measures to maintain a low-calorie diet A: For the client with CRF, dietary protein should be decreased to limit the accumulation of end products of metabolism in the blood. 9. Which of the following clinical manifestations would the nurse expect to assess in a client diagnosed with a duodenal ulcer? a. Low-grade fever and left lower quadrant pain b. Aching or gnawing pain in the right epigastrium, relieved by eating c. Burning in the upper epigastrium 30 to 60 minutes after meals d. Severe localized diffuse abdominal pain and rebound tenderness B: With a duodenal ulcer, the patient typically complaints of aching or gnawing pain in the right epigastrium, relieved by eating. Pain also occurs 2 to 3 hours after meals and may awaken the client at night. 10.Which of the following interventions would be included in the plan of care for a client experiencing heat stroke? a. Avoiding massaging the client b. Using a hyperthermia blanker c. Immersing the client in ice cold water d. Sponging the client with cool water D: For the client with heat stroke, the goal is to reduce the body temperature as quickly as possible. Sponging the client with cool water is one effective method. Additionally, cool sheets or towels also may be used.

11. A preoperative client has doubts about the upcoming surgery and does not want to sign the informed consent. Which of the following should the nurse do next? a. Notify the surgeon of the clients failure to sign b. Have a responsible family member sign the consent form c. Explain to the client that it must be signed d. Have another nurse get the client to sign the form A: If a client does not want to sign the consent form, the surgeon must be notified. The client cannot be forced to sign the consent or be urged to sign it. If the client has doubts about the surgery, a second opinion can be requested. 12.Which of the following client statements would indicate a possible problem with peripheral vascular function? a. I often have pain near my upper right rib and back after eating a heavy meal b. I stopped smoking last year, but I still have difficulty breathing sometimes. c. I can feel my heart beating in my abdomen when I am lying down d. I get pain in my legs when I walk down the street more than two blocks. D: complaints of pain in the legs with activity are a cardinal sign of arterial insufficiency. 13.Which of the following would the nurse do to help minimize the risk of bacterial growth during a transfusion? a. Inspect blood for abnormal color b. Warm blood prior to transfusion c. Begin transfusion slowly and monitor closely d. Transfuse blood within 4 hours D: Transfusing blood within 4 hours and changing the blood tubing every 4 hours are appropriate measure to help decrease the risk for bacterial growth. The longer the blood is allowed to hang at room temperature, the greater the risk for microbial growth. 14. When teaching a group of women about Breast Health Awareness (BHA) and Breast Self-Examination (BSE) at a local community center, the nurse

follows the American Cancer Society recommendations. Which of the following would the nurse include in the teaching a. Quarterly BSE until the age of 70 after which BHA and BSE are no longer necessary b. Yearly BSE and follow up clinical examinations every 6 months after onset of menses c. Monthly BSE, a yearly clinical examination, and yearly mammograms after age 40 d. Bi-monthly BSE and yearly mammograms beginning after the woman has had her first child C: BHA recommends monthly BSE after menses begins, a yearly clinical examination, and yearly mammograms after age 40 15.Which of the following interventions would be most appropriate when caring for the client with osteomyelitis? a. Administering colchicine nonsteroidal anti-inflammatory drugs (NSAIDs) and

b. Removing the traction weights every 4 hours and performing range-ofmotion exercises c. Assessing the neurovascular status of the affected limb frequently d. Maintaining the affected limb in the dependent position C: For the client with osteomyelitis, the nurse must assess the neurovascular status of the affected extremity; the 6 Ps to minimize the risk of complications. 16.While caring for a client with deep venous thrombosis (DVT), the client develops a sudden onset of severe leg pain. The limb becomes pale, cold, numb, and pulseless. Which of the following would the nurse suspect? a. Dissecting aneurysm b. Acute arterial occlusion c. Postphlebitic syndrome d. Raynauds phenomenon B: The change in color, temperature, sensation, and pulse accompanied by the sudden onset of pain (the classic Ps of assessment) all suggest an acute arterial occlusion 17.Which of the following would the nurse expect to assess in a client with emphysema?

a. Distant breath sounds b. Cor pulmonale c. Copious sputum d. Cyanosis A: With emphysema, air trapping and chronic hyperexpansion of the lungs lead to distant breath sounds. 18.For the client with iron deficiency anemia receiving iron therapy, the nurse would encourage the intake of which of the following vitamins? a. Vitamin B12 b. Niacin c. Vitamin C d. Vitamin D C: iron absorption is increased in an acid environment. Thus, vitamin C (ascorbic acid) enhances iron absorption. 19. When assessing a client who has an abdominal aortic aneurysm, the nurse monitors the client for which of the following? a. Intermittent episodes of high fever with chills b. Positive Homans sign and calf pain c. Paresthesias and loss of position sense d. Pulsatile mass and systolic bruit D: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm 20. Which of the following would be included in the plan of care for a client with an immune system disorder? a. Prevention of the development of immunity b. Prevention of injury to skin and mucous membranes c. Promotion of the histamine (H1) reaction response d. Promotion of the inflammatory response B: the person with an immune system disorder would have an increased risk for infection. The bodys first line of defense against infection is intact skin and mucous membranes. Thus, measures would be used to

prevent injury to skin and mucous membranes to minimize the risk of infection. 21.When obtaining a history of a client admitted with endocarditis, which of the following would the nurse consider as most significant? a. History of coronary artery disease b. History of marijuana use c. Prolonged use of steroid therapy d. Dental surgery in the recent past D: Dental surgery is one of the predisposing factors for the development of endocarditis, creating a portal of entry for microorganisms 22.A client with angina is prescribed nitroglycerin tablets sublingually. Which of the following statements indicates that the medication teaching plan has been successful? a. Ill keep it with me, carrying it in my plastic pill container box b. Ill get a new supply every 6 months even if I dont use them all up c. I should get relief from the chest pain about 15 minutes after I take the drug d. I swallow the tablet with a large glass of water when I have chest pain B: Nitroglycerin sublingual tables are inactivated by heat, moisture, air, light, and time. The client should renew his or her supply every 6 months to ensure that the current medications are potent 23. Which of the following clinical manifestations would lead the nurse to suspect that the client with a fracture of the left femur is experiencing a fat emboli. a. Diminished capillary refill, cyanotic nailbeds, and Paresthesias b. Complaints of shortness of breath, restlessness, and petechiae over the chest c. High fever, chills, and purulent drainage from a skin abscess d. Great toe joint swelling, pruritus, and low back pain. B: A systematic fat embolus is a life-threatening even, most commonly developing within 24-72 hours after fracture. The manifestations are similar to those for a pulmonary embolism, such as shortness of breath and restlessness. Additionally, chest petechiae, personality changes, crackles, on auscultation, and white sputum are noted.

24.When caring for a client with hypoparathyroidism experiencing tetany, which of the following interventions would demonstrate the nurses understanding of the potential complications? a. Monitoring for signs and symptoms of transient diabetes insipidus b. Preparing the client for an adrenalectomy c. Padding the siderails for possible seizures d. Assessing for the development of ketoacidosis C: Life-threatening tetany may result in seizures. Therefore instituting seizure precautions, including padding the siderails, demonstrates the nurse understands about the potential injury that may occur secondary to the development of seizures. 25.A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary. Which of the following would the nurses best response? a. This will relieve your distress and help you be more comfortable b. This is diagnostic surgery done to confirm or rule out malignancy c. The physician removes the precancerous mass to prevent cancer from occurring d. This will provide a more realistic look to the body part. B: a biopsy is performed to aid in diagnosing whether a mass is benign or malignant. 26. Which of the following would the nurse identify as indicative of a clients altered peripheral vascular function? a. Ankle arm index pressure of 0.4 b. Pulses graded as being +4 c. Capillary refill time less than 3 seconds d. Diastolic blood pressure of 84 mm Hg A: The ankle arm index is an objective indicator of arterial disease. Normal value is 1.0. Values less than 0.5 indicate ischemic rest pain 27. The client with uric acid renal calculi is being discharged from the hospital. Discharge teaching would include which of the following? a. Instructing the client to decrease fluid intake at night b. Explaining the importance of restricting dietary calcium

c. Explaining the importance of avoiding foods high in purine d. Encouraging the intake of increased amounts of organ meats C: uric acid stones result from the breakdown of purines. Therefore, the client should avoid foods high in purines, such as shellfish, anchovies, asparagus, and organ meats. 28.Which of the following would the nurse anticipate administering for the client with idiopathic thrombocytopenia (ITP) who experiences an acute bleeding episode? a. Administration of vitamin K b. Splenectomy c. Administration of cryoprecipitate d. Heparin administration B: A splenectomy would be the treatment of choice because it will help prevent further sequestration of platelets. Other treatment modalities might include administration of steroids and gamma globulin 29.The nurse would expect to assess which of the following clinical manifestations in the client diagnosed with multiple sclerosis (MS)? a. Weakness of muscles after activity, drooping facial muscles, and ptosis b. Resting tremors, muscle rigidity, and mask-like facial expressions c. Ascending paralysis of the lower extremities and Paresthesias d. Muscle weakness, diplopia, and nystagmus D: MS is a progressive demyelinating disease affecting nerve fibers of the brain and spinal cord, resulting in visual problems, motor problems, fatigue, and mental changes. 30.The nurse would assess which of the following clinical manifestation in the client diagnosed with serious otitis media? a. Plugged feeling in ear, reverberation of own voice, and hearing loss b. Itching, pain, and watery discharge c. Sudden episodes of severe whirling vertigo, tinnitus, and nausea d. Bright red, bulging tympanic membranes, fever, and throbbing ear pain. A: plugged feeling in ear, reverberation of own voice and hearing loss are clinical manifestations of serious otitis media

31.Which of the following signs and symptoms would in the nurse expect to find when assessing a client with fluid volume deficit? a. Flat neck veins and decreased urine specific gravity b. Polyuria and increased blood pressure c. Rales and decreased lung sounds d. Fever and elevated white blood cell count A: Flat neck veins and decreased urine specific gravity are typical assessment findings in client with fluid loss 32. One day after undergoing a right total hip replacement, which of the following would be appropriate? a. Maintaining the right leg in abduction with an abductor pillow b. Avoiding use of sequential compression devices on the right leg c. Monitoring the continuous passive motion machine (CPM) d. Elevating the head of the bed (HOB) to 90 degrees A: Following a right total hip replacement, the right leg should be kept in abduction using abductor pillow. This helps to prevent dislocation of the prosthesis. 33. Which of the following outcomes would best demonstrates client understanding about measures to prevent the spread and transmission of infection? a. Verbalization of the need to cover mouth when coughing b. Regaining skin and mucous membrane integrity c. Demonstration of proper handwashing after using the toilet d. Maintenance of temperature within normal range without complications C: Demonstration is the best indicator that a client has understood the teaching and is able to incorporate the information into his usual practices. By demonstrating handwashing, the client is complying with the instructions. 34. The client experiencing a contact dermatitis due to poison ivy notes that the rash has spread to his periorbital and groin areas. The client also reports the itching is much worse. Which of the following should the nurse do? a. Notify the physician since the clients complaints have worsened b. Hold the steroids and request an order to discontinue medication

c. Instruct the client to continue with the current regimen d. Have the client take frequent hot baths A: these findings represent a deterioration of the clients condition, which could have profound consequences. The nurse should notify the physician because the client requires additional medical intervention. 35.Which of the following manifestations would the nurse expect to assess in a client diagnosed with compartment syndrome? a. Atrophy of muscles associated with contractures b. Mild discomfort and deformity c. Absent pulse and excessive redness and warmth d. Pain excessive for visibly injury and tight, shiny skin D: Compartment syndrome is edema within a muscle compartment. Most commonly, the skin appears taut and shiny and the clients complaints of pain are out of proportion to the visible injury. Include decreased capillary refill, cyanotic distal tips, absent pulse, paresthesias, and weakness 36. Which of the following nursing intervention would the nurse institute immediately for the newly admitted client diagnosed with a seizure disorder? a. Padding the head and foot of the bed b. Placing the client on seizure precautions c. Keeping the bed in a high position with side rails down d. Placing a padded tongue blade at the head of the bed B: Seizure precautions should be instituted for a client with a seizure disorder to minimize the risk of injury should a seizure occur. Seizure precautions include padding side rails, keeping an oral airway at bedside, maintaining the bed in a low position with side rails up, and making sure all staff are aware of the seizure disorder 37.A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which of the following would the nurse do next? a. Call the physician b. Check the CPK-MG level c. Prepare the client for angioplasty

d. Get a 12-lead EKG D: For the client experiencing chest pain, obtaining a 12-lead EKG is a priority to reveal possible changes occurring during an acute angina attack that will be helpful in treatment 38. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever of 100.6, and is moderately dyspneic. Which of the following would the nurse suspect? a. Aspiration pneumonia b. Pleural effusion c. Chronic obstructive pulmonary disease d. Pneumoconiosis A: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by the hacking cough, low-grade fever, and moderate dyspnea. 39.After experiencing an allergic reaction to a wasp sting, the client is being prepared for discharge. The nurse knows that teaching has been effective when the client states which of the following? a. I will carry my anti-sting kit whenever I go outside b. Ill return to the emergency room if Im stung again. c. I know which type of wasp stung me, so I will avoid it d. Ill be sure to take anti-venom when I go outside A: an anti-sting kit is used immediately to counteract the bodys reaction to allergen. Having the kit with the client whenever outside provides the client with ready access should a sting occur, possibly warding off a severe anaphylactic reaction 40. The nurse is providing discharge teaching for a client with suppurative otitis media. To prevent forcing contaminated material into the inner ear canal, the nurse would instruct the client to do which of the following? a. Tilt the head sideways when using ear drops b. Use nasal decongestants during colds c. Wear ear plugs when around loud noises d. Blow the nose with the mouth and nostrils open. D: By keeping the mouth and nostrils open when blowing the nose, the client will avoid forcing mucus into his inner ear.

41.After teaching a group of 16-year-old girls about menstrual flow, which of the following terms, if identified by the group as referring to indicate effective teaching? a. Amenorrhea b. Metrorrhagia c. Menorrhagia d. Dysmenorrhea C: menorrhagia is a type of abnormal uterine bleeding defines as excessive bleeding at the usual time of menstrual flow. 42. When providing post-operative care after a bowel resection to the client with a pre-existing history of COPD with frequent exacerbations, for which of the following would the nurse be alert? a. Airway obstruction b. Pneumothorax c. Atelectasis d. Acute respiratory failure D: the client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubation, the anesthesia used during surgery, and the experience of surgery. 43.A client arrives in the emergency room following a motor vehicle accident with multiple injuries to the head, chest, and extremities with minimal bleeding. Which of the following would the nurse assess first? a. Level of consciousness b. Quality of peripheral pulses c. Airway status d. Blood pressure C: when dealing with an emergency, the ABCs airway, breathing, and circulation are the priorities. Airway management is a basic function and must be established and maintained first. 44. Following a thoracentesis, which of the following assessment findings would warrant immediate interventions by the nurse? a. Symmetrical respirations b. Auscultation of crackles bilaterally

c. Complaints of pain at the needle insertion site d. Prolonged periods of uncontrolled coughing D: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention. 45. Which of the following would be included in the plan of care for a patient experiencing an acute exacerbation of chronic inflammatory bowel disease a. Assessing the client for fluid volume overload b. Instructing the client to eat cold foods and decrease smoking c. Monitoring the clients intake and output every 12 hours d. Administering intravenous fluid therapy D: For the client with a severe acute exacerbation of chronic inflammatory bowel disease, fluid and electrolyte loss can be great because of the profuse episodes of diarrhea. Thus fluid and electrolyte replacement usually is administered intravenously to reduce the clients risk for fluid volume deficit and electrolyte imbalances. 46. Which of the following client complaints would lead the nurse to suspect premenstrual syndrome? a. Painful menstruation and large menstrual flow b. Fatigue and weight gain on the day prior to menses c. Mood swings and breast tenderness with the onset of menses d. Headache and mood swings occurring about 10 days prior to menses D: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle. 47. Which of the following instructions should be included in the teaching plan for a client receiving antibiotic therapy for acute prostatitis? a. Explaining the importance of remaining on bedrest b. Instructing the client to abstain from sexual intercourse c. Teaching the client to cleanse the glans and prepuce after each voiding d. Discussing the care of the Foley catheter needing to be inserted B: Abstinence is encouraged during antibiotic therapy in acute prostatitis, although in chronic prostatitis, sexual intercourse is encouraged.

48. When assessing a client preoperatively, the nurse would identify which of the following as a major psychological factor affecting a clients response to surgery? a. Intellectualization b. Body image concerns c. Regression d. Anxiety D: Anxiety is one of the major psychological factors affects a clients response to surgery. Thus preoperative teaching is performed to help alleviate or minimize this anxiety. Gear is also another major psychological factor. 49.When caring for the client with diabetic ketoacidosis (DKA), which of the following parameters will the nurse monitor closely? a. Plasma osmolarity for urine concentration b. Serum calcium for hypercalcemia c. Plasma cortisol for elevation d. Arterial blood gases for pH value. D: as the name implies, acidosis is possible. The major means for monitory acidosis is with arterial blood gases, primarily the pH level. 50.When assessing an elderly client who has been on prolonged bedrest, the nurse observes a break in the skin through the epidermis with a shallow crater on the hip. Based on this assessment, the nurse identifies this wound as a pressure ulcer, documenting that it is at a. Stage I b. Stage II c. Stage III d. Stage IV B: a stage II pressure ulcer appears as a break in the skin through the epidermis or dermis. An abrasion, blister, or shallow crater may be present. 51.Discharge teaching for the client diagnosed with psoriasis would include discussing which of the following medical treatments? a. Antibiotics and silver nitrate compresses b. Coal tar therapy and cytotoxic therapy

c. Systemic corticosteroids and antibiotics d. Immunosuppressive agents and plasmapheresis. B: Treatment for psoriasis may include photochemotherapy, and cytotoxic therapy. coal tar therapy,

52. Which of the following would the nurse assess in the client who experienced a full-thickness burn? a. Mottled appearance with waxy white injured areas b. Painful erythematous area without blisters c. White, cherry red, or black in color, without pain d. Red to pale ivory with wet, thin-walled blisters C: A full thickness burn involves destruction of the entire epidermis and dermis. The area appears to be dry and leathery, and ranges in color from white to cherry red to black. Pain is absent because all superficial nerve endings have been destroyed. 53.A client with pulmonary edema is receiving mechanical ventilation with positive end expiratory pressure (PEEP). When explaining to the student about the rationale for using PEEP, the nurse would include which of the following as its major purpose? a. Allows the client to obtain needed rest b. Improves area available for gas exchange c. Increases the clients CO2 level d. Increases pulmonary capillary pressure. B: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange, thus improving the clients oxygenation. 54.A client who has suffered a right-sided cerebrovascular accident (CVA) who has a left-sided paralysis and manifests unilateral neglect. When developing the clients plan for rehabilitation focusing on the problem of unilateral neglect, which of the following would be most helpful? a. Providing a calendar, clock, and pictures to help with orientation b. Placing objects within the clients field of vision c. Providing physical therapy and range-of-motion exercises d. Telling the client repeatedly to use to left side. B: unilateral neglect is an inability of a client to recognize the existence of one side of the body. Placing objects within the field of vision allows

the client to help with self-care activities, thus participating in his or her own care by increasing the use of the neglected side. 55. While caring for a client with a new amputation, the dressing inadvertently comes off the stump. Which of the following should the nurse do? a. Maintain the client in a supine position to improve peripheral blood flow b. Wrap the limb in an elastic compression bandage immediately c. Elevate the limb above the level of the heart to promote venous return d. Apply a large tourniquet at bedside to prevent massive haemorrhage. B: Because excessive edema will develop in a short time, resulting in delays in rehabilitation, the nurse should wrap the limb with an elastic compression bandage immediately. 56. When caring for the client with Menieres disease, which of the following areas would be the primary concern? a. Sensory and perceptual alteration b. Impaired physical mobility c. Increased risk for injury d. Severe pain C: because of the vertigo associated with Menieres, there is a high risk for injury for these clients. 57.When caring for the client with allergic rhinitis, which of the following would be most appropriate to include in the patients plan of care? a. Administering gamma globulin after an exposure to the allergen b. Teaching the client discontinuing it to taper oral corticosteroid dosage when

c. Advising the client to use a nasal decongestant spray for a least 3 to 4 weeks d. Administering antihistamines and oral decongestants D: Antihistamines, oral decongestants, and topical steroids such as in nasal sprays, are used to treat allergic rhinitis. 58.When assessing a client with Graves disease, which of the following would the nurse expect to find? a. Renal calculi, polyuria, and polydipsia b. Heat intolerance, hyperreflexia, and frequent stools

c. Hirsutism, edema, and symptoms of hyperglycemia d. Cold intolerance, delayed, muscle contractions, and constipation. B: Heat intolerance, hyperreflexia, and frequent stools are clinical manifestations of hyperthyroidism, where the bodys metabolism is increased. 59. A client recently treated for Neisseria gonorrhea comes to the clinic complaining of fever and acute labial pain. She exhibits a red, swollen vulva with a visible nodule. Which of the following would the nurse suspect? a. Bartholinitis b. Syphilis c. Pelvic inflammatory disease d. Atrophic vaginitis A: Bartholinitis is inflammation of the Bartholin glands located near the vaginal opening and at the base of the labia majora. It frequently occurs following an infection and is characterized by unilateral pain and swelling. An abscess can occasionally be seen. 60.The client with a closed head injury is obtunded with a Glasgow Coma Score of 3. The pupils are fixed and dilated, the blood pressure has gone from 140/94 to 170/62, and the heart rate has gone from 84 to 42. The client is exhibiting which of the following? a. Cushings triad b. Curlings syndrome c. Impaired cerebral perfusion d. Cerebral edema A: Cushings triad is characterized by increasing systolic blood pressure, decreasing diastolic pressure, and bradycardia. It is indicative of brain stem involvement and impending herniation. 61.The client who has been receiving long-term glucocorticoid therapy begins developing extra weight gain, moon face, and a buffalo hump. The nurse would explain that this is most likely a result of which of the following? a. Excessive thyroid hormone production b. Their treatment for Addisons disease c. Oversecretion of antidiuretic hormone d. Defective pancreatic beta cell function

B: Long-term glucocorticoid therapy is the treatment for Addisons disease and may result in Cushings syndrome, commonly manifested by weight gain, moon face, and a buffalo hump. 62. The nurse is obtaining a health history from a client with tuberculosis (TB). Which of the following information should the nurse recognize as pertinent to the diagnosis? a. Severe abdominal cramping and stools test positive for ora b. Hemoptysis and cough with a positive Candida antibody test c. Mucopurulent sputum and a positive Mantoux test d. Tachypnea and blood cultures positive for Staphylococcus aureus C: Tuberculosis is an infection caused most commonly by Mycobacterium tuberculosis, characterized by mucopurulent sputum. The Mantoux test, a skin test for tuberculosis, identifies exposure to the mycobacterium 63.The nurse knows the client with COPD understands the discharge teaching when the client sates which of the following? a. I need to drink at least 2 liters of fluid every day b. I should smoke only when I am not having difficulty breathing c. I should do everything in the morning so I can rest later on d. I need to take a sleeping pill every night so I wake up rested. A: Secretions are often very thick and difficult to expectorate for clients with COPD. Therefore, drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. 64. When preparing the discharge teaching plan for a client with stomatitis, which of the following would be included? a. Using a hard bristle toothbrush for mouth care b. Instructing the client to eat a bland diet c. Discussing the importance of eating spicy and acidic foods d. Instructing the client to gargle with mouthwash B: to promote adequate food and fluid intake while minimizing the effects of stomatitis, the client should eat a bland diet and avoid spicy and acidic foods. 65.Which of the following assessment findings would lead the nurse to suspect that a client has experienced retinal detachment? a. Pain, decreased accommodation, and tunnel vision

b. Cloudy-appearing lens and loss of vision c. Blurred vision, floating spots, and visual field defects d. Colored halos around lights and red eye with severe pain C: With retinal detachment, blurred vision, visual floaters, and visual field defects are noted. Additionally, recurrent flashes of light may be seen. Ophthalmoscopic exam reveals a gray, opaque retina with holes and tears. 66.Which of the following actions is most appropriate for a client who is 12 days post-chemotherapy and being admitted with shortness of breath, a dry hacking cough, and a temperature of 101F? a. Initiate the prescribed IV antibiotics after checking the WBC count b. Have the dietary department serve the meals as hot as possible c. Reassure the client that fatigue is a common occurrence after chemotherapy d. Limit the protein and calories in the clients diet A: The client is probably neutropenic due to a low neutrophil count on the WBC. This occurs as a result of myelosuppressive activity of the chemotherapy. This is further confirmed by the clients symptoms of infection. 67. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations, which of the following would be included? a. Administration of antibiotics b. Deep breathing and coughing exercises c. Administration of oxygen as needed d. Eliminating exposure to pulmonary irritants. D: one aspect of prevention of prevention of exacerbation focuses on eliminating the causes and contributory factors associated with the disease. One of the major causes or contributing factors for COPD is pulmonary irritants, such as smoke, air pollution, occupational irritants, and allergies. Thus prevention would focus on eliminating these irritants. 68. Which of the following would alert the nurse to a problem requiring immediate intervention for the client with a newly applied above-the-knee cast? a. Assessment of a hot spot on the cast

b. Smooth cast edges with no breaks or ragged edges c. Use of a soft bristle toothbrush by the client to alleviate an itch d. The ability to insert two fingers under the cast. A: Hot spots, if noted on a cast, could indicate an infection under the cast. Evidence of a hot spot requires immediate intervention and notification of the physician. 69.Which of the following is the most important aspect to address when completing preoperative teaching for the client undergoing abdominal surgery? a. Incisional care b. Prognosis after surgery c. Pain control techniques d. Need for prophylactic antibiotics C: the client needs to be aware of and understand that pain will occur after surgery and that medications are available to control the pain. 70.The nurse would expect to assess which of the following in the client diagnosed with herpes zoster (shingles)? a. Thin-walled, honeycombed vesicles around the hands and mouth b. Small, red, scaly patches around the groin extending to the thighs c. Inflamed red rash along the soles of the feet and between the toes d. Painful vesicular eruptions along a route of inflamed nerves D: Herpes zoster is an infection caused by varicella zoster virus manifested by painful vesicular eruptions along the route of inflamed nerves. Usually unilateral, the inflammation appears as a band of typically involving the thoracic, cervical, or cranial nerves. Itching may precede or accompany the eruption. 71.When evaluating a clients risk for developing cancer, which of the following clients would the nurse identify as having the highest risk? a. Oncology nurse who takes vitamins C and E daily b. New breast-feeding mother who works in a bank c. Vegetarian who works at a convenience store d. Asphalt road construction worker who eats meats and potatoes

D: exposure to certain chemicals such as tar, soot, asphalt, oils, and sunlight put this occupation at the highest risk. Additionally, meat and potatoes are low fiber, contributing to the risk of cancer. Plus, some processed meats contain chemicals that have been implicated in the development of cancer. 72.The nurse would include which of the following in the plan of care for client with an L5-S1 intervertebral disc herniation? a. Assessing the skeletal traction insertion for sites of infection b. Positioning with head of bed elevated and kneed slightly flexed c. Encouraging the client to ambulate as much as possible d. Preparing the client for lumbar puncture B: Positioning the client with the head of the bed elevated and the knees slightly flexed increases the disc space and may help to decrease to clients pain. 73.When disposing of the plastic bags, tubing, syringes, and gloves used to administer the antineoplastic drugs, the nurse should do which of the following? a. Discard all used equipment in a container marked isolation b. Dispose of all used equipment in the regular trash receptacles c. Dispose of all equipment in a container marked bio-health hazard d. Avoid contact with the equipment by allowing housekeeping to remove it. C: any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment. Placing the items in a container marked bio-health hazard is appropriate because these containers can be incinerated at a temperature of 2200 to 2500 F so that there is no residue. 74.The clinical manifestations of a client in end-stage renal disease would include which of the following? a. Polyuria, nocturia, and signs and symptoms of mild anemia b. Altered urine output, which may be oliguria or anuria c. Widespread systemic manifestations including fluid volume overload d. No symptoms as long as there is no exposure to physiologic stress C: the client with end-stage renal disease typically exhibits symptoms affecting multiple body systems.

75.When planning the nursing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which of the following would the nurse most likely do? a. Give insulin and monitor serum potassium levels b. Force fluids and withhold thiazide diuretics c. Administer furosemide (Lasix) and restrict fluids d. Provide eye protection, such as patches or Artificial Tears C: the client with SIADH is experiencing excessive water retention and subsequent hyponatremia. Thus diuretics, such as furosemide, are given to promote excretion of the excess water, and fluids are restricted to prevent additional fluid overload and to aid in regaining sodium balance.