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<Q>The
<TYPE>single</TYPE>
client is 8 hours status-post (S/P) partial thyroidectomy for Graves' dis
ease. What is the best documentation by the nurse of evaluation outcome criteria
<MC1>Dressing
for the nursing is clean
diagnosis:
dry and
Riskintact,
for ineffective
pain minimal airway
and controlled,
clearance?</Q>alert and or
<MC2>Vital signs stable; client supports neck with hand during change of positio
iented.</MC1>
<MC3>No tracheal
n.</MC2>
<MC4>Balanced intake
stridor,
and output,
speaks vital
clearly,signs
andstable,
denies and
numbness
alertorandtingling.</MC3>
oriented.</MC
<F>Rationale: Laryngeal nerve damage can occur as a result of a thyroidectomy ma
<CORRECT>3</CORRECT>
4>
nifested by stridor, a weak or a harsh voice (option 3). An early sign of edema
of the larynx leading to airway obstruction is a tight-fitting dressing. Numbnes
s or tingling or the extremities, lips, or mouth is a sign of hypocalcemia that
can lead to respiratory distress due to tetany (also in option 3). The data in t
he other options are important routine postoperative assessments, but they do no
t relateNeed:
Cognitive
Client
Integrated
Content
Strategy: Area:
specifically
Level:
This
Process:
Physiological
Adult
item
Application
Nursing
Health:
requires
to a Integrity:
thyroidectomy
Process:
Endocrine
knowledgeEvaluation
Reduction
and
ofand
Metabolic
the the
common
ofclient's
Risk
complications
Potential
airway. following a t
hyroidectomy. While all of the distracters are important in post-op care, select
Reference:
the one that
LeMone,
is directly
P., & Burke,
relatedK.to(2008).
the surgery
<i>Medical-surgical
performed. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 539.</F>
<Q>Which
<TYPE>single</TYPE>
<P>
</P> of the following evaluation data would best lead the nurse to conclude
that the client with hyperglycemic hyperosmolar state (HHS) has demonstrated imp
rovement during
<MC1>Alert and oriented,
the firstbalanced
24 hours?</Q>
intake and output, moist mucous membranes</MC1
><MC2>Intakeand
<MC3>Alert equals
oriented,
output,blood
deniesandpain
urineandwithout
shortness
ketones,
of breath</MC2>
no orthostatic BP</MC3
><MC4>Respirations easy and even, eats 50 to 75% of meals, vital signs stable</MC
<F>Rationale: HHS results from hyperglycemia, causing excessive loss of water an
<CORRECT>1</CORRECT>
4>
d retention of glucose that leads to dehydration, hypernatremia, and hypokalemia
. Symptoms are dry, tenting skin, dry mucous membranes, altered level of conscio
usness, and hyperthermia (option 1). Ketones are not present in HHS; thus, monit
oring for ketones is unnecessary (option 3). Pain and shortness of breath are un
related to HHS (option 2). Amount of dietary intake is unrelated to HHS (op-tion
Cognitive
Client
Integrated
Content
Strategy:
4). Need:
Area:
Level:
The
Process:
Physiological
Adult
pathophysiology
Application
NursingIntegrity:
Health: Process:
Endocrine
of HHS isEvaluation
Physiological
anddirectly
Metabolic related
Adaptation
to dehydration. Select
the distracter
Reference: LeMone,
thatP.,
best& Burke,
representsK. (2008).
improvement
<i>Medical-surgical
in this condition.nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 585-586.</F>
is caring for a client with type 1 diabetes mellitus. In developing
a teaching plan, which of the following signs and symptoms of hypoglycemia shou
ld the nursebreath</MC4>
<MC2>Increased
<MC1>Shakiness</MC1>
<MC4>Fruity
<MC3>Fever</MC3>
<F>Rationale:
<CORRECT>1</CORRECT>
include?</Q>
The
thirst</MC2>
signs of hypoglycemia include hunger, shakiness, sweating, pal
e cool skin, and irritability (option 1). These signs may be manifestations of i
mpaired cerebral function from the hypoglycemia. The other options are all signs
Cognitive
Client
Integrated
Content
Strategy:
of hyperglycemia.
Need:
Area:
Level:
Differentiate
Process:
Physiological
Adult
Application
Teaching/Learning
Health:
theIntegrity:
Endocrine and
presentation Reduction
for
Metabolic
hypoglycemia
of Risk Potential
and hyperglycemia. Sel
ect the distracter
Reference: LeMone, P.,that&isBurke,
consistent
K. (2008).
with <i>Medical-surgical
the hypoglycemic symptoms.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 586-587.</F>
is caring for a client who is taking 4 units of regular insulin and
30 units of NPH insulin at 08:00. The nurse keeps which of the following in min
d regardingvial
<MC1>Client
<MC2>Client
<MC3>Shake
<MC4>Administer
<MC5>Neither
<F>Rationale:
<CORRECT>[1,2,4]</CORRECT>
this
may
insulin
Regular
experience
of
room
regimen?
insulin
temperature
can
insulin
beSelect
hypoglycemia
to
administered
disperse
is all that
insulin
rapid insulin
acting
shortly
atonly.</MC4>
intravenously.</MC5>
apply.</Q>
dinnertime.</MC2>
with
particles
after
an onset
breakfast.</MC1>
evenly.</MC3>
of action within 15-
30 minutes of administration. Its peak time is about 2-4 hours after administrat
ion, which is the most likely time for hypoglycemia to develop (option 1). NPH i
s an intermediate-acting insulin with an onset of action of 1-2 hours, a peak ti
me of 4-12 hours, and a duration of 24 hours, so the client could experience hyp
erglycemia at dinnertime (option 2). Insulin should be administered at room temp
erature to avoid lipid atrophy caused by cold insulin (option 4). Shaking of the
insulin vial creates bubbles that lead to dosage error (option 3). Only regular
Cognitive
Client
Integrated
Content
Strategy:
insulinNeed:
Area:
can
Level:
The
Process:
becore
Physiological
Adult
administered
Application
issue
Nursing
Health:
ofIntegrity:
Process:
Endocrine
the
IV,question
not Implementation
NPH
Pharmacological
and insulin
is
Metabolic
knowledge
(option
andinformation
of 5).
Parenteral related
Therapiesto
both NPH and regular insulins. Evaluate each option and select the options that
represent true statements. Recall the time for the onset of action and peak acti
on and the correct procedure for administering insulin to help make the correct
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
choices.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.postsurgical
<Q>A
<TYPE>single</TYPE>
<P>
</P> 571-572.</F>client is brought back to the nursing unit following a thyroid
ectomy. Which of the fol-lowing methods should the nurse use to assess for bleed
<MC1>Inspectlatest
ing?</Q>
<MC2>Change
<MC3>Check dressing
dressing
hemoglobin
applied
for signs in determine
to of hemorrhage.</MC1>
the operating
if there
room.</MC2>
has been a drop in value.</MC
<MC4>Palpate back
3>
<F>Rationale:
<CORRECT>4</CORRECT>
The danger
of neckofandhemorrhage
shouldersisforgreatest
evidenceduring
of bleeding.</MC4>
the first 24 hours fol
lowing thyroid surgery. The tendency is for blood to follow gravity and flow dow
n at the sides and posteriorly if hemorrhage occurs in the area of the neck (opt
ion 4). Inspecting the dressings for signs of hemorrhage may not reveal bleeding
(option 1). Changing dressings immediately after surgery is not appropriate (op
tion 2). A drop in hemoglobin may be a clue to bleeding but is not the best init
ial assessment
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
Eliminate
Process:
Physiological
Adult
action
Analysis
Nursing
Health:
distracters
(option
Integrity:
Process:
Endocrine
3).that are
Assessment
Reduction
and unrelated
Metabolic
of and
Risktake
Potential
a significant amount
of time that could pose a risk to the client. Select the distracter that is imm
ediate and LeMone,
Reference: reflectsP., the&placement
Burke, K.of(2008).
the dressing
<i>Medical-surgical
and client positioning.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.diabetic
<Q>A
<TYPE>single</TYPE>
<P>
</P> 539.</F>client with the flu asks why he should drink juices, check his fin
gerstick glucose every 4 hours, and take insulin when he is not eating and is vo
miting. What
<MC1>"You needwould
to prevent
be the dehydration
best explanationand monitor
by the for
nurse?</Q>
hyperglycemia and excessiv
e breakdownneed
<MC2>"You of to
fatscheck
for your
glucose."</MC1>
blood glucose because vomiting could cause hypoglyc
emia and drinking
<MC3>"Your body uses fluids
protein
willforprevent
energydehydration."</MC2>
during times of illness, causing increas
ed ketonesyouandcanhypoglycemia."</MC3>
<MC4>"If substitute water for the juices to prevent dehydration, then yo
u won't need toStarvation-induced
<F>Rationale:
<CORRECT>1</CORRECT>check your blood ketosis glucose can
levels
be prevented
so often."</MC4>
by drinking juices tha
t equal the prescribed carbohydrate meal pattern. Fluids are needed to prevent d
ehydration and hyperosmolality, which could result from large fluid losses from
persistent vomiting (option 1). The liver breaks down fats, not proteins, to for
m glucose for energy and ketones, leading to DKA (option 3). Options 2 and 4 do
not address
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
Select
Process:
the
Physiological
Adult
core
Application
the Teaching/Learning
Health:
issuesIntegrity:
distracterof dehydration
Endocrine
that best
Physiological
and Metabolic
reflect
and hyperglycemia.
theAdaptation
pathophysiology of diabete
s. Both choices
Reference: LeMone,in P.,
a distracter
& Burke, K. must(2008).
be correct.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 580.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> client with diabetic ketoacidosis (DKA) is given intravenous (IV) normal
saline infusion and regular insulin. In addition to hourly blood glucose monitor
ing, the nurse would look to what assessment data as early signs of clinical imp
<MC1>Respiratory
rovement?</Q>
<MC2>Temperature
<MC3>Improved
<MC4>Client
<F>Rationale:
<CORRECT>3</CORRECT>
eats
level
LOC rate
aand
responds
full
ofpulse
ofconsciousness
meal
12quickly
intoand
normal
15respiratory
and
to(LOC)
range</MC2>
normaland
early changes
BPdecreasing
rate
inisstanding
innormal</MC4>
pH and
urine
position</MC1>
restoration
output</MC3>
of flu
id and electrolyte balance. In addition, urine output decreases as hyperglycemia
resolves (option 3). The respiratory buffer system takes a few hours to respond
to change in pH, and the respiratory rate is likely to come down just into norm
al range rather than drop to the lower end of normal (option 1). Dehydration is
usually so severe that several hours of rehydration are needed to reduce pulse (
option 2) and resolve orthostatic BP (option 1). Option 4 is wrong because eatin
g a fullNeed:
Cognitive
Client
Integrated
Content
Strategy: Area:
meal
Level:
Recall
Process:
Physiological
is that
AdultnotHealth:
Analysis
Nursing
antheearly
LOC
Integrity:
Process:
Endocrine
signoneofof
is Evaluation
improvement.
Physiological
andtheMetabolic
last changes
Adaptation
in the development of D
KA and the first to return to normal. Select the distracter that is consistent w
ith this fact.
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 582-584.</F>
is preparing to discharge a client newly diagnosed with diabetes me
llitus. The client states, "I should eat a candy bar or cup of ice cream every t
ime I feel shaky, hungry, or nauseated." What would be the best response by the
<MC1>"Yes, a candy bar or cup of ice cream is needed to treat the hypoglycemia."
nurse?</Q>
<MC2>"Yes, you should eat the snack, then have a meal as soon as possible."</MC2
</MC1>
><MC3>"No, you should quickly eat a meal; the candy will cause hyperglycemia."</M
<MC4>"No, these have too much sugar and fat; 5 Lifesavers candy or skim milk are
C3>
<F>Rationale:
<CORRECT>4</CORRECT>
better choices."</MC4>
The candy bar and ice cream may have too much glucose and fat, pot
entially leading to hyperglycemia or not being absorbed quickly enough to revers
e the hypoglycemia (options 1 and 2). Immediate absorption of glucose is needed
in hypoglycemia, which can be achieved with concentrated simple carbohydrates (o
ption 4). A meal would not be absorbed quickly enough to raise the serum glucose
(option 3). The client should also check the blood glucose within 15 minutes of
Cognitive
Client
Integrated
Content
Strategy:
takingNeed:
glucose.
Area:
Level:
Differentiate
Process:
Health
AdultApplication
Promotion
Nursing
Health:the absorption
Process:
Endocrine
and Maintenance
Implementation
and
rateMetabolic
for simple versus complex carbohydra
tes. Select the distracter with the fastest absorption rate for immediate relief
Reference:
of symptoms.
LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 586-587.</F>
had a bilateral adrenalectomy for Cushing's syndrome and is being
sent home with a new prescription for hydrocortisone. The best statement indicat
ing understanding
<MC1>"I am taking this
of thedrug drugtoand
replace
associated
the hormones
risk is:</Q>
usually secreted by the adre
nal medulla."</MC1>
<MC2>"I
<MC3>"This
should
pilltake
may cause
this pillweightevery
gain,
morning
so I should
before exercise
breakfast."</MC2>
more and eat less."<
<MC4>"I should call the doctor if I think I am starting a cold, and I should not
/MC3>
<F>Rationale:
<CORRECT>4</CORRECT>
take aspirin."</MC4>
Hypersecretion of the adrenal cortex (not the medulla) causes Cush
ing's disease (option 1). Normally, the secretion of cortisol is increased in re
sponse to stress, infection, or a significant increase in activity. Thus, the re
placement dose during illness may need to be adjusted once a client's adrenal gl
ands are removed (option 3). Hydrocortisone can irritate gastric mucosa, so clie
nts should not take gastric irritants such as aspirin or nonsteroidal anti-infla
mmatory drugs (NSAIDs) (option 4). Hydrocortisone is usually taken twice a day f
ollowingNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
anIdentify
Level:
Process:
adrenalectomy
Health
Adult
Analysis
the
Promotion
Nursing
Health:
hormone
(option
Process:
Endocrine
and
secreted
2).Evaluation
Maintenance
andbyMetabolic
the adrenal medulla and cortex. Elimi
nate distracters that refer to the adrenal medulla. Select the distracter that m
inimizes theLeMone,
Reference: side effects
P., & Burke,
of theK.hydrocortisone.
(2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.elderly
<Q>An
<TYPE>single</TYPE>
<P>
</P> 550, 553.</F>
female client with dry flaky skin and activity intolerance seconda
ry to myxedema is admitted to the progressive care unit to improve her activity
tolerance and gain independence in self-care. For hygiene care the nursing order
is two total baths per week on Saturday and Wednesday with partial baths on the
remaining days of the week. Which of the following would be the desired outcome
<MC1>Client
of this intervention?</Q>
is able to sleep through the night and stay awake most of the day</M
<MC2>Gradual increase
C1>
<MC3>Increased energy byin the
ambulation
end of the
ability
firstover
weektheoffirst
pacedmonth</MC2>
rest and activity</M
<MC4>Intact elastic
C3>
<F>Rationale:
<CORRECT>4</CORRECT>
Daily total
moist baths
warm skin
remove
by the protective
end of firstsebum
week</MC4>
from the skin, placi
ng the client at risk for altered skin integrity (option 4). Since the client's
level of participation in the bath or other self-care activity is not presented,
the other 3 options are inappropriate. In addition, options 2 and 3 are not spe
cific and
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
measurable
Level:
Define
Process:
Physiological
Adult
Application
myxedema
Nursing
Health:
enoughand
Integrity:
toits
Process:
Endocrine
meetsymptoms.
criteria
Planning
Physiological
and Metabolic
Choose
for antheoutcome
Adaptation
distracter
statement.
directly relat
ed to skin LeMone,
Reference: care concerns
P., & Burke,
found inK.this
(2008).
population.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 555-556.</F>
</P>