CARDIAC
What is the first intervention for a client experiencing MI?
A. Administer morphine
B. Administer oxygen
C. Administer sublingual nitroglycerin
D. Obtain an ECG
B. Administer oxygen
Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI.
The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?
Silvery-white scaly lesions
The nurse assesses a patient admitted to the medical-surgical unit who has a diagnosis of type I diabetes mellitus. The nurse notes that the patient's urine is cloudy and foul-smelling. Which of the following diagnostic tests does the nurse anticipate will be ordered based on this finding?
1. urine culture and sensitivity (C&S)
2. blood urea nitrogen (BUN)
3. creatinine clearance
4. residual urine
Correct Answer: 1
Rationale: Urine culture and sensitivity (C&S) is correct because cloudy and foul-smelling urine indicates a urinary tract infection. The diagnostic test to identify the organism responsible is a urine C&S. Blood urea nitrogen (BUN) measures the amount of urea (end product of protein metabolism) in the blood plasma. It does not identify infection. Creatinine clearance is a 24-hour urine test used to identify renal function; it will not identify an infection. Residual urine measures the amount of urine left in the bladder after voiding, and does not identify an infection.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?
a) Give medications that promote fluid retention.
b) Limit sodium and water intake.
c) Teach client behaviors that decrease urination.
d) Assess for dehydration.
B) Limit sodium and water intake
Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
Which of the following blood tests is most indicative of cardiac damage?
A. Lactate dehydrogenase
B. Complete blood count (CBC)
C. Troponin I
D. Creatine kinase (CK)
C. Troponin I
Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury
A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?
A. Black.
B. Green.
C. Red.
D. Yellow.
D. Yellow.
The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW.
Which assessment finding would indicate a need for possible glaucoma testing? (Select all that apply.)
1. Presence of "floaters"
2. Halos around lights
3. Progressive loss of peripheral vision
4. Pruritus and erythema of the conjunctiva
5. Lack of ability to adapt to darkness
2,3,5
A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement?
A: Dysphagia
B: Positive Babinski sign
C: Decreased deep tendon reflexes
D: Ataxia
A: Dysphagia
(difficulty swallowing may occur as a result of the cranial nerves IX -glossopharyngeal & V -vagus nerve.)
The nurse is teaching a client with cardiomyopathy about home care safety measures. Which most important instruction should the nurse provide?
A. Reporting pain
B. Taking vasodilators
C. Avoiding over-the-counter medications
D. Moving slowly from a sitting to a standing position
D. Moving slowly from a sitting to a standing position
Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety
Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?
A. Heart failure
B. Diabetes
C. MI
D. Pericardial effusion
A. Heart failure
Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.
The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?
Darken the room for the examination.
A nurse is teaching a nursing student about the effects of a sustained drop in systemic blood pressure on the juxtaglomerular cells of the distal tubules in the kidneys. The nurse knows teaching has been effective when the student states, "This juxtaglomerular cell response to low blood pressure is utilized with the medication
1. captopril (Capoten)."
2. digoxin (Lanoxin)."
3. furosemide (Lasix)."
4. adenosine (Adenocard)."
Correct Answer: 1
Rationale: A sustained drop in systemic blood pressure triggers the juxtaglomerular cells to release renin. Renin acts on a plasma globulin, angiotensinogen, to release angiotensin I, which is in turn converted to angiotensin II. As a vasoconstrictor, angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. Captopril (Capoten) is an ACE inhibitor, which blocks the conversion of angiotensin I to the vasodilator angiotensin II. The other drugs are not ACE inhibitors.
A nurse is preparing to admit a client with myasthenia gravis who has been having increasingly frequent episodes of myasthenic crises. Because of the client's history, which of the following equipment should the nurse ask the AP to place at the client's bedside?
A: Metered dose inhaler & peak flow meter
B: Incentive spirometer & cough pillow
C: Suction machine & suction catheters
D: External defibrillator pads and telemetry monitor
C: Suction machine & suction catheters
Which of the following tests is used most often to diagnose angina?
A. Chest x-ray
B. Echocardiogram
C. Cardiac catheterization
D. 12-lead electrocardiogram (ECG)
D. 12-lead electrocardiogram (ECG)
The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with variant angina, the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement or signs of heart failure, but isn't used to diagnose angina.
When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to?
A. Do oral and nasal suctioning.
B. Provide oxygen therapy.
C. Initiate intravenous access.
D. Immobilize the cervical area.
D. Immobilize the cervical area.
Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Options A, B, and C: Suctioning, oxygen therapy, and intravenous access are also done after the cervical spine is immobilize.
A client has been diagnosed with acute angle closure glaucoma. The nurse should expect the client to report
A: Showers of floaters
B: Flashes of light across the eye
C: Eye pain and blurred vision
D: Double vision
C: Eye pain and blurred vision
A nurse is assessing a client who was just admitted to the hospital for observation following a closed-head injury. Which of the following is the most essential nursing assessment to detect early signs of a worsening condition?
A: Vital signs
B: Body posture
C: LOC
D: Focal neurological exam
C: LOC
The home health nurse is performing an initial assessment on a client who has arrived home after insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident?
A. "I will never be able to operate a microwave oven again."
B. "I should expect occasional feelings of dizziness and fatigue."
C. "I will take my pulse in the wrist or neck daily and record it in a log."
D. "Moving my arms and shoulders vigorously helps check pacemaker functioning."
C. "I will take my pulse in the wrist or neck daily and record it in a log."
The home health nurse is performing an initial assessment on a client who has arrived home after insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident?
Rationale:
Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.
Which of the following types of angina is most closely related with an impending MI?
A. Angina decubitus
B. Chronic stable angina
C. Nocturnal angina
D. Unstable angina
D. Unstable angina
Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.
The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?
Elevation above the level of the heart
A nurse is performing discharge teaching with a patient who had a cystogram. The nurse should instruct the patient to use which of the following techniques to promote comfort? Select all that apply.
1. Take a sitz bath.
2. Increase oral fluid intake.
3. Take acetaminophen for minor pain.
4. Apply heat to the lower back.
5. Drink one ounce of brandy or rum with warm water.
Correct Answer: 1,2,3
Rationale: Appropriate techniques for relieving pain after a cystogram include taking a sitz bath, increasing oral fluid intake, and using over-the-counter analgesics that do not promote bleeding. Apply heat to the lower abdomen, not the lower back. Tell the patient to avoid alcoholic drinks for two days and that a slight burning sensation with voiding may occur for a day or two.
The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first?
A. A 42-year-old patient with multiple sclerosis who was admitted with sepsis
B. A 72-year-old patient with Parkinson's disease who has aspiration pneumonia
C. A 38-year-old patient with myasthenia gravis who declined prescribed medications
D. A 45-year-old patient with amyotrophic lateral sclerosis who refuses enteral feedings
C. A 38-year-old patient with myasthenia gravis who declined prescribed medications
Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop a myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which actions should the nurse implement in the postprocedure period? Select all that apply.
A. Restricting visitors
B. Checking the client's groin for bleeding
C. Encouraging the client to increase fluid intake
D. Placing the client's bed in the high Fowler's position
E. Instructing the client to move the toes when checking circulation, motion, and sensation
A, C, E
Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion?
A. Warming the blood prior transfusion.
B. Informing the client that the transfusion usually takes 4 to 6 hours.
C. Documenting blood administration in the client chart.
D. Instructing the client to report any itching, chest pain, or dyspnea.
D. Instructing the client to report any itching, chest pain, or dyspnea.
This will help the nurse take immediate action in case a reaction happens during a transfusion.
A client with myopia asks the nurse about the possibility of LASIK surgery. The nurse tells the client that which of the following is a commonly experienced side effect following LASIK surgery?
A: Eyelid tics and twitching
B: Photosensitivity
C: Excessive tearing
D: Halos and glaring while driving at night
D: Halos and glaring while driving at night
A bolus of mannitol (Osmitrol) is ordered for a client with a closed-head injury showing manifestations of increasing intracranial pressure. Prior to administration, assessment shows: UO 40 mL/hr, apical HR 88/min, and the pupils equal and reactive. The client is sleepy but easily aroused. After administering mannitol to the client, which of the following should indicate to the nurse that the medication is having the desired effect?
A: UO is 100 mL/hr
B: Pupils are dilated
C: HR is 62/min
D: Client is difficult to rouse
A: UO is 100 mL/hr
(osmotic diuretic used to ↑ UO and ↓ cerebral edema)
The nurse in the emergency department is assessing a client with chest pain. Which finding should help the nurse determine that the pain is caused by myocardial infarction (MI)?
A. The client experienced no nausea or vomiting.
B. The pain was described as burning and gnawing.
C. The client reports that the pain began while pushing a lawnmower.
D. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate.
D. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate.
Which of the following conditions is most commonly responsible for myocardial infarction?
A. Aneurysm
B. Heart failure
C. Coronary artery thrombosis
D. Renal failure
C. Coronary artery thrombosis
Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn't cause an MI. Renal failure can be associated with MI but isn't a direct cause. Heart failure is usually a result from an MI.
A patient with an allergy to iodine is scheduled to have the following diagnostic tests. Which requires immediate nursing intervention?
1. renal angiogram
2. renal scan
3. voiding cystogram
4. portable ultrasonic bladder scan
Correct Answer: 1
Rationale: An angiogram includes the use of contrast dye, which often contains iodine. The nurse should contact the primary healthcare provider to report the iodine allergy. The other tests do not use contrast media.
In formulating the teaching plan for a patient who is taking metformin (Glucophage), the nurse should include which of these priority instructions? Notify your healthcare provider if
1. you need a diagnostic test that uses iodinated contrast.
2. your urine becomes orange or red-tinted.
3. your urine becomes more concentrated.
4. you need an intermittent or indwelling urinary catheterization.
Correct Answer: 1
Rationale: Oral hypoglycemic agents are contraindicated for use with iodinated contrast, as the combination of the two can precipitate renal failure. Patients should be taught to inform all healthcare providers if they have a prescription for an oral hypoglycemic agent. Orange or red-tinted urine, concentrated urine, or needing urinary catheterizations have no interaction with metformin.
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient?
A. Provide multivitamins with each meal.
B. Provide a diet that is low in complex carbohydrates and high in protein.
C. Provide small, frequent meals throughout the day that are easy to chew and swallow.
D. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
C. Provide small, frequent meals throughout the day that are easy to chew and swallow.
Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow.
A client is scheduled for a cardiac catheterization. Which data, if noted in the client's health record, should the nurse report to the health care provider before the catheterization?
A. Allergy to shellfish
B. History of hypertension
C. Client slept poorly through the night
D. History of coronary artery disease (CAD)
A. Allergy to shellfish
Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following?
A. Intake and output.
B. NPO standing order.
C. Vital signs.
D. Skin turgor
Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following?
A. Intake and output.
B. NPO standing order.
C. Vital signs.
D. Skin turgor
A nurse obtains frequent vital signs of a client who is at risk for IOP. The previous vital signs were a BP of 120/70 mm Hg and a HR of 92/min. The nurse should be concerned if the next set of vital signs obtained are a:
A: BP of 160/65 mm Hg and HR of 68/min.
B: BP of 140/100 mm Hg and HR of 68/min.
C: BP of 150/100 mm Hg and HR of 112/min.
D: BP of 80/40 mm Hg and HR of 112/min.
A: BP of 160/65 mm Hg and HR of 68/min.
(IOP causes a widening of the pulse pressure -difference between systolic & diastolic, and a decreasing HR and increasing temperature)
A nurse is reading the results of a lumbar puncture (LP) performed on a client suspected of having bacterial meningitis. Which of the following findings should the nurse recognize as being consistent with this diagnosis?
A: Elevated glucose
B: Elevated protein
C: Presence of RBC
D: Presence of D-dimer
B: Elevated protein
(typically CSF has a higher proportion of glucose than protein, an elevated protein is consistent with meningitis)
The nurse is assessing a client who has been hospitalized with acute pericarditis for signs of complications. For which manifestation of cardiac tamponade should the nurse monitor the client?
A. Bradycardia
B. Paradoxical pulse
C. Flattened jugular veins
D. Bounding heart sounds
B. Paradoxical pulse
Which of the following results is the primary treatment goal for angina?
A. Reversal of ischemia
B. Reversal of infarction
C. Reduction of stress and anxiety
D. Reduction of associated risk factors
A. Reversal of ischemia
Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply. An infarction is permanent and can't be reversed.
Which of these assessments of an 86-year-old patient requires immediate nursing intervention?
1. reports of urinary incontinence
2. reports of urinary frequency
3. reports of urinary urgency
4. reports of nocturia
Correct Answer: 1
Rationale: Urinary incontinence is not a normal part of aging and requires immediate nursing intervention. Reports of urinary frequency, urgency, and nocturia are more common in older adults than in younger people. These may represent normal changes expected with aging.
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
a) "The effluent should be allowed to drain by gravity."
b) "It is important to use strict aseptic technique."
c) "The infusion clamp should be open during infusion."
d) "It is appropriate to warm the dialysate in a microwave."
D) It is appropriate to warm the dialysate in a microwave
Explanation: The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
The nurse is caring for a patient who sustained a fall with a fractured femur and was unable to summon help or receive healthcare treatment for 48 hours. On arrival at the emergency department, the patient's blood urea nitrogen level is 50 mg/dL. The serum creatinine level is 1.0 mg/dL. These findings would help substantiate a nursing diagnosis of which of the following?
1. Deficient Fluid Volume
2. Anxiety related to crisis
3. Acute Pain
4. Impaired Nutrition
Correct Answer: 1
Rationale: To assess if the patient's elevated blood urea nitrogen is caused by dehydration or renal failure, the nurse assesses the serum creatinine value. The patient's serum creatinine is normal, which does not indicate kidney failure. A nursing diagnosis of Deficient Fluid Volume is appropriate for this patient.
A client is admitted to a telemetry unit with a potassium (K+) level of 6.3 mEq/L. In analyzing the cardiac rhythm, which electrocardiogram (ECG) changes should the nurse anticipate?
A. A sinus rhythm with a peaked T wave
B. A sinus tachycardia with an extra U wave
C. A sinus rhythm with a depressed ST segment
D. A sinus tachycardia with a prolonged QT interval
A. A sinus rhythm with a peaked T wave
The nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). What should the nurse plan to do in delivering care to this client?
A. Begin thrombolytic therapy.
B. Place the client on continuous cardiac monitoring.
C. Infuse intravenous (IV) fluid at a rate of 150 mL per hour.
D. Administer oxygen at a rate of 6 L per minute by nasal cannula
B. Place the client on continuous cardiac monitoring.
Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 liters per minute unless otherwise prescribed
A nurse is educating a client who was just dianosed with open angle glaucoma about the condition. Which of the following information should the nurse include in the teaching? (Select all that apply)
A: Do not take cold medications that contain pseudoephedrine.
B: Expect impaired night vision.
C: Glasses will be necessary to correct the accompanying presbyopia.
D: Driving may be dangerous due to loss of peripheral vision.
A: Do not take cold medications that contain pseudoephedrine.
B: Expect impaired night vision.
D: Driving may be dangerous due to loss of peripheral vision.
E: Laser surgery can help reestablish the flow of aqueous humor.
A nurse is caring for a client with Guillain-Barre syndrome. Upon assessment, the nurse should anticipate that the client will exhibit which of the following?
A: Tonic-clonic seizures
B: Complaints of a severe headache and nausea
C: Weakness of the lower extremities
D: Decreased level of consciousness
C: Weakness of the lower extremities.
The nurse is monitoring a client hospitalized with acute pericarditis for signs of cardiac tamponade. Which finding is associated with cardiac tamponade?
A. Bradycardia
B. Hypertension
C. Bounding heart sounds
D. Distended jugular veins
D. Distended jugular veins
Which of the following is a compensatory response to decreased cardiac output?
A. Decreased BP
B. Alteration in LOC
C. Decreased BP and diuresis
D. Increased BP and fluid retention
D. Increased BP and fluid retention
The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water. Blood pressure doesn't initially drop in response to the compensatory mechanism of the body. Alteration in LOC will occur only if the decreased cardiac output persists.
An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.
36%
When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?
a) Check for thrill or bruit over the access site.
b) Warm the solution to body temperature.
c) Inspect the catheter insertion site for infection.
d) Add the prescribed drug to the dialysate.
A) Check for thrill or bruit over the access site. When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.
Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)?
A. Acute confusion
B. Bowel incontinence
C. Activity intolerance
D. Disturbed sleep pattern
C. Activity intolerance
The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
The nurse is providing preoperative teaching for a patient scheduled for a cystogram. The nurse knows follow-up is needed when the patient states, "After the procedure, I need to contact my primary healthcare provider if I experience
1. bloody urine."
2. low urine output."
3. abdominal pain."
4. chills or fever."
Correct Answer: 1
Rationale: Some blood is expected in the urine following the procedure. The nurse should provide more information regarding the monitoring of blood in the urine. The nurse should instruct the patient to immediately notify the physician if the urine remains bloody for more than three voidings after the procedure, or if bright bleeding develops. Low urine output, abdominal or flank pain, chills, or fever do not identify blood in the urine although these complications can occur.
A client is being brought into the emergency department after suffering a head injury. Which should the nurse assess first?
A. Level of consciousness
B. Pulse and blood pressure
C. Respiratory rate and depth
D. Ability to move extremities
C. Respiratory rate and depth
The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the neurological status (options 1 and 4).
nurse is assessing a client who is reporting a sore throat, pressure in the ear, decreased hearing, and mild dizziness. The client has been treating himself for a cold for 1 week. The nusre should expect an alteration of which of the following structures?
A: The temporomandibular joint
B: The inner ear
C: The external ear
D: The middle ear
D: The middle ear
A nurse understands that a client with a seizure disorder, who frequently experiences an aura is describing a:
A: Sensory warning that a seizure is imminent.
B: Continuous seizure state in which seizures occur in rapid succession.
C: Period of sleepiness following the seizure, during which arousal is difficult.
D: Brief loss of consciousness accompanied by staring.A: Sensory warning that a seizure is imminent.
(client may report hearing bells, seeing lights or smelling something)A client has undergone surgical repair via scleral buckling of a detached retina of the left eye with an injection of a gas bubble. The nurse should anticipate that the surgeon will prescribe the client to assume which postoperative position?
A: Semi-fowler's position while wearing shaded dilation glasses
B: Prone position with operated eye up.
C: Left lateral position with the eye shield on the left eye.
D: Trendelnburg position without a pillow.B: Prone position with operated eye up.
A: Sensory warning that a seizure is imminent.
(client may report hearing bells, seeing lights or smelling something)
The nurse should expect a client experiencing an acute myocardial infarction to manifest which pattern first on the electrocardiogram?
A. Absent P waves
B. T wave elevation
C. ST segment elevation
D. An abnormal Q wave
C. ST segment elevation
Which of the following terms describes the force against which the ventricle must expel blood?
A. Afterload
B. Cardiac output
C. Overload
D. Preload
A. Afterload
Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled by the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.
he nurse is preparing an education program on risk factors for kidney disorders. Which of the following risk factors would be inappropriate for the nurse to include in the teaching program?
a) Pregnancy
b) Diabetes mellitus
c) Neuromuscular disorders
d) Hypotension
D) Hypotension
Hypertension, not hypotension, is a risk factor for kidney disease.
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
a) Urine output of 250 ml/24 hours
b) Temperature of 100.2° F (37.8° C)
c) Serum creatinine level of 1.2 mg/dl
d) Blood urea nitrogen (BUN) level of 22 mg/dl
A) Urine output of 250 ml/24 hours
ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.
The home care nurse is doing an admission assessment on a client discharged from the hospital with a diagnosis of PD. When assessing the client's neurological status, the nurse would find a client with:
A. Impaired mental acuity
B. A shuffling and propulsive gait
C. An intention tremor
D. Droopy eyelids
B. A shuffling and propulsive gait
A public health nurse is performing teaching for a patient who will be obtaining a sample of urine for a urinalysis at home. Which of these patient comments will cause the nurse to provide clarifying information?
1. "I will get the specimen as soon as I get home this evening."
2. "I won't touch the inside of the cup or lid."
3. "I will refrigerate the specimen until I bring it to the laboratory tomorrow."
4. "I will give the laboratory a list of the medications I am taking."
Correct Answer: 1
Rationale: An early morning specimen is preferred. The patient is bringing the specimen to the laboratory tomorrow, so an early morning specimen is possible and the most accurate and useful specimen. The other options are correct information.
When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to
a. suction the mouth and oropharynx.
b. immobilize the cervical spine.
c. administer supplemental oxygen.
d. obtain venous access
When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to
a. suction the mouth and oropharynx.
b. immobilize the cervical spine.
c. administer supplemental oxygen.
d. obtain venous access
A nurse in a clinic is providing teaching to an adolescent client who has been diagnosed with swimmer's ear, or external otitis for the 3rd time in 2 months. The nurse should instruct the client to:
A: dry the ear with a cotton swab after swimming.
B: Instill hydrogen peroxide into the ear after swimming.
C: Instill diluted alcohol into the ear after swimming.
D: Dry the ear with a twisted paper towel wick after swimming.
C: Instill diluted alcohol into the ear after swimming.
In which of the following positions should a nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe?
A: Supine
B: Prone
C: Semi-fowlers
D: Sims
C: Semi-fowlers
(head midline and the HOB elevated 30, allowing blood flow to the brain while allowing venous drainage, ↓ risk of IOP)
A client, without history of respiratory disease, has experienced sudden onset of chest pain and dyspnea and is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client?
A. Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV)
B. Supine position, oxygen, and meperidine hydrochloride (Demerol) intramuscularly (IM)
C. High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3)
D. High Fowler's position, oxygen, and meperidine hydrochloride (Demerol) intravenously (IV)
A. Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV)
Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. The supine position will increase the dyspnea that occurs with pulmonary embolism. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
When developing a teaching plan for a client with endocarditis, which of the following points is most essential for the nurse to include?
A. "Report fever, anorexia, and night sweats to the physician."
B. "Take prophylactic antibiotics after dental work and invasive procedures."
C. "Include potassium rich foods in your diet."
D. "Monitor your pulse regularly."
A. "Report fever, anorexia, and night sweats to the physician."
The most essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician. To prevent further endocarditis episodes, prophylactic antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures. A potassium-rich diet and daily pulse monitoring aren't necessary for a client with endocarditis.
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:
a) a decreased serum phosphate level secondary to kidney failure.
b) an increased serum calcium level secondary to kidney failure.
c) water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
d) metabolic alkalosis secondary to retention of hydrogen ions.
C) water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
Explanation: The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
Retention of which electrolyte is the most life-threatening effect of renal failure?
a) Potassium
b) Calcium
c) Phosphorous
d) Sodium
A) Potassium
Retention of potassium is the most life-threatening effect of renal failure.
During assessment of a patient admitted to the hospital with an acute excerbation of MS, what should the nurse expect to find?
A. tremors, dysphasia, and ptosis
B. bowel and bladder incontinence and loss of memory
C. motor impairment, visual disturbances, paresthesias
D. excessive involuntary movements, hearing loss, ataxia
C. motor impairment, visual disturbances, paresthesias
All of the following diagnostic tests are ordered for a patient with renal disease. The nurse understands that which one of the following will be used in the evaluation of the patient's glomerular filtration rate (GFR)?
1. creatinine clearance
2. blood urea nitrogen (BUN)
3. intravenous pyelogram (IVP)
4. renal ultrasound
Correct Answer: 1
Rationale: Creatinine clearance is correct because this study (a 24-hour urine) measures the ability of the kidney to clear a given amount of creatinine out of the plasma within a given time period. Creatinine is a substance produced from the breakdown of muscle and is cleared by the kidney at a constant rate. This test is used to determine the glomerular filtration rate or the ability of the kidney to clear substances out of the plasma. Blood urea nitrogen (BUN) measures the amount of urea in the plasma and, although it is reflective of kidney function, it can be affected by both protein intake and fluid balance. Intravenous pyelogram (IVP) identifies the structures of the urinary system, not the function. Renal ultrasound identifies renal or perirenal masses or obstructions.
A client is transferred to a rehab center 3 weeks following a cerebrovascular accident (CVA). The client's CVA involved the left side of the brain. Which of the following goals should the nurse anticipate including in the client's rehabilitation program?
A: Improving left-side motor function
B: Establishing the ability to communicate effectively
C: Learning to control impulsive behavior.
D: Keeping the left side of the body safe.
B: Establishing the ability to communicate effectively.
A nurse is caring for a client who has sustained a high thoracic spinal cord injury following a diving accident. The nurse suspects that the client may be experiencing the complication of autonomic dysreflexia when the client exhibits:
A: Rhinorrhea
B: Hypotension
C: Tachycardia
D: A severe headache
D: A severe headache
A client with Meniere's disease is hospitalized for recurring episodes caused by the disease. The nurse should anticipate documenting which of the following measures to help prevent exacerbation of the disease in the client's plan of care?
A: Avoid bearing down (valsalva maneuver)
B: Increase fluid intake
C: Avoid sudden movements
D: Increase sodium intake
C: Avoid sudden movements
he nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
a) "My urine will be eliminated with my feces."
b) "A catheter will drain urine directly from my kidney."
c) "I will not need to worry about being incontinent of urine."
d) "My urine will be eliminated through a stoma."
D) My urine will be eliminated through a stoma
An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall.
A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for:
A. Hypotension and dizziness
B. Nausea and vomiting
C. Hypertension and headache
D. Flat neck veins
A. Hypotension and dizziness
The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
A small elevation on the skin that contains no fluid,but may develop pus is a ___________.
Papule
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
a) History of hyperparathyroidism
b) History of osteoporosis
c) Recent history of streptococcal infection
d) Previous episode of acute pyelonephritis
C) Recent hx of streptococcal infection
Explanation: Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.
which observation of the patient made by the nurse is most indicative of PD?
A. large, embellished handwriting
B. weakness of one leg resulting in a limp walk
C. difficulty rising from a chair and beginning to walk
D. onset of muscle spasms occurring with voluntary movement
C. difficulty rising from a chair and beginning to walk
A nurse is reviewing the laboratory test results of a client with renal disease. Which of the following would the nurse expect to find?
a) Decreased blood urea nitrogen (BUN)
b) Decreased potassium
c) Increased serum albumin
d) Increased serum creatinine
D) Increased serum creatinine
In clients with renal disease, the serum creatinine level would be increased. The BUN also would be increased, serum albumin would be decreased, and potassium would likely be increased.
An unconscious client assumes a decerebrate position in response to any noxious stimuli. When drawing a blood sample, the nurse should expect the client to:
A: Rigidly extend all four extremities.
B: Internally flex the arms and extend the legs.
C: Tightly curl into a fetal positon.
D: Internally rotate the arms and legs.
A: Rigidly extend all four extremities.
A nurse is talking to a client's spouse about degenerative complications associated with Parkinson's disease. The highest priority topic for the nurse to talk to the spouse about is the risk for:
A: Aspiration
B: Emotional lability
C: Impaired speech
D: Self-care dependency
A: Aspiration
(priority because it could lead to choking)
A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI?
A. Heart failure
B. Cardiogenic shock
C. Cardiac dysrhythmias
D. Recurrent myocardial infarction
C. Cardiac dysrhythmias
Dysrhythmias are the most common complication and cause of death after an MI. Heart failure, cardiogenic shock, and recurrent MI are also complications but occur less frequently.
he nurse suspects that a client who had a myocardial infarction is developing cardiogenic shock. The nurse should assess for which peripheral vascular manifestation of this complication?
A. Flushed, dry skin with bounding pedal pulses
B. Warm, moist skin with irregular pedal pulses
C. Cool, clammy skin with weak or thready pedal pulses
D. Cool, dry skin with alternating weak and strong pedal pulses
C. Cool, clammy skin with weak or thready pedal pulses
Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin.
Dark, brown patches on the skin that may appear uneven in texture, jagged, or raised may be a warning sign of:
Malignant melanoma .
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the student have understood the material when they identify which of the following as a cause of stress incontinence?
a) Obstruction due to fecal impaction or enlarged prostate
b) Bladder irritation related to urinary tract infections
c) Increased urine production due to metabolic conditions
d) Decreased pelvic muscle tone due to multiple pregnancies
D) Decreased pelvic muscle tone due to multiple pregnancies
Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.
A patient with PD is started on levodopa. What should the nurse explain about this drug?
A. it stimulates dopamine receptors in the basal ganglia
B. it promotes the release of dopamine from brain neurons
C. it is a precursor of dopamine that is converted to dopamine in the brain
D. it prevents the excessive breakdown of dopamine in the peripheral tissues
C. it is a precursor of dopamine that is converted to dopamine in the brain
A client has just been admitted to the emergency department with chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis?
A. Stable angina
B. Unstable angina
C. Prinzmetal's angina
D. New-onset myocardial infarction (MI)
D. New-onset myocardial infarction (MI)
A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:
A. Premature ventricular contractions
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Sinus tachycardia
B. Ventricular tachycardia
Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.
A nurse is caring for a client who was admitted secondary to transient ischemic attacks (TIA). The goal of therapy for the client is:
A: Reversal of disability
B: Reduction of cerebral bleeding
C: Reduction in cerebral edema
D: Prevention of a cerebrovascular accident.
D: Prevention of a cerebrovascular accident
A nurse explains to a family of a client recently diagnosed with amyotrophic lateral sclerosis (ALS) that early manifestations typically include:
A: Sensory dysfunction
B: Weakness of the distal extremities
C: Decreased cognitive functioning
D: Altered temperature regulation
B: Weakness of the distal extremities
The nurse is developing a plan of care for a client with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
A. Assess peripheral circulation.
B. Monitor for abdominal distention.
C. Tell the client that abdominal pain is expected.
D. Turn the client to the side to look for ecchymoses on the lower back.
E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
A, B, D
If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk