Nutrition
A nurse is caring for a client with Wernicke-Korsakoff syndrome. The physician asks the nurse to teach the client to consume thiamine-rich food. The nurse instruct the client to increase the intake of which food items?
A. Chicken.
B. Milk.
C. Beef.
D. Brocolli.
Answer: C
Food sources of thiamine include beef, liver, nuts, oats, oranges, pork, eggs, seeds, legumes, peas and yeast. Option A: Poultry contains niacin. Option B: Milk contains vitamins A, D, and B2. Option D: Brocolli contains folic acid, vitamins C, E, and K.
A client is receiving theophylline intravenously. After several dosages, the client started to become restless and complains of palpitations. The nurse determines that the client is experiencing theophylline toxicity in which of the following?
A. Theophylline level of 10mcg/ml
B. Theophylline level of 15mcg/ml
C. Theophylline level of 20mcg/ml
D. Theophylline level of 25mcg/m
Answer: D
Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/ml. Early signs of toxicity include restlessness, nervousness, tachycardia, tremors and palpitations
In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled?
A. An osmotic diuretic
B. A miotic agent
C. A mydriatic medication
D. A thiazide diuretic
Answer: C, also called Tropicamide
A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract
A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly “water” weight. In addition, they report the patient hasn’t been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient’s HR is 115 and BP 180/92. Patient sodium level is 90
In the scenario above what drug do you anticipate the patient will be started on per doctor’s order?
A. Desmopressin (DDAVP) IV
B. Declomycin
C. Diabinese
D. Stimate
Answer: B
A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
Answer: D
Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don’t have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary instructions if she selects which of the following from her menu?
A. Nuts and fish.
B. Oranges and dark green leafy vegetables.
C. Butter and margarine.
D. Sugar and candy
Answer: B
Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption.
A 9-year-old child has been prescribed with lithium as a mood stabilizer. His lab results shows his lithium level of 2.0 mmol/L. The priority nursing diagnosis for this child should be:
A. Activity Intolerance
B. Risk for Aspiration
C. Ineffective Therapeutic Regimen Management
D. Disturbed Thought Process
Answer: B
Children who develop lithium toxicity are prone to seizures and coma. Due to the seizures that can occur the child is at risk for aspiration during seizure. This can also occur if the child is comatose. Based on Maslow's hierarchy of needs, maintaining a paten airway is the priority nursing diagnosis.
The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?
A. Notify the physician
B. Irrigate the eye with cold water
C. Apply ice to the affected eye
D. Accompany the client to the emergency room
Answer: C
Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
1. The client has a three (3)-pound weight gain.
2. The client has a decreased pulse rate.
3. The client's temperature is WNL.
4. The client denies any diaphoresis.
Answer: 3
The client with hypothyroidism frequently has a subnormal temperature,so a temperature WNL indicates the medication is effective.
1. The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state.
2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective.
4. Diaphoresis (sweating) occurs with hyper-thyroidism, not hypothyroidism
The nurse is preparing to administer the following medications. Which medication should the nurse question administering?
1. The thyroid hormone to the client who does not have a T3, T4 level.
2. The regular insulin to the client with a blood glucose level of 210 mg/dL.
3. The loop diuretic to the client with a potassium level of 3.3 mEq/L.
4. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.
Answer: 3
This potassium level is below normal,which is 3.5 to 5.5 mEq/L. Therefore,the nurse should question administering this medication because loop diuretics cause potassium loss in the urine.
1. The thyroid hormone must be administered daily, and thyroid levels are drawn every six (6) months or so.
2. A blood glucose level of 210 mg/dL requires insulin administration; therefore,the nurse should not question administering this medication
4. The digoxin level is within therapeutic range—0.8 to 2.0 mg/dL; therefore, the nurse should administer this medication.
A patient who has a colostomy is complaining about having excess gas. You ask the patient to tell you what he has ate in the past 48 hours. Which food would you suspect is causing the patient excessive gas?
A. Cherries, Radishes, and Watermelon
B. Caraway seeds, tomato soup, and eggs
C. Chicken, grapes, and raspberries
D. Squash, Spinach, and Pickles
Answer: A
Cherries, Radishes, and Watermelon are gas causing foods and should be decreased in consummation if a patient is experiencing excess gas
An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse evaluates the client's status as being most satisfactory if the total protein is which value?
1. 0.4 g/dL
2. 3.7 g/dL
3. 6.4 g/dL
4. 9.8 g/d
Answer: 3
Rationale- The normal range for total serum protein level in the adult client is 6 to 8 g/dL. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. The options of 0.4 g/dL. and 3.7 g/dL identify low values, and 9.8 g/dL identifies a high protein value.
The nurse has notes that the physician has a diagnosis of presbycusis on the client’s chart. The nurse plans care knowing the condition is:
A. A sensorineural hearing loss that occurs with aging
B. A conductive hearing loss that occurs with aging.
C. Tinnitus that occurs with aging
D. Nystagmus that occurs with aging
Answer: A
Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply.
1.Fever
2.Nausea
3.Lethargy
4.Tremors
5.Confusion
6.Bradycardia
Answer: 1,2,4 &5
Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.
Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer?
a. pack the ulcer with foam dressing
b. turn and position the patient every hour
c. clean the ulcer every shift with Dakin's solution
d. assess for pain and medicate before dressing change
Answer: C
Dakin solution is cytotoxic and will further damage wound/impead wound healing.
The patient is on a low potassium diet that includes food such as applesauce, green beans, cabbage, lettuce, grapes, and raspberries. What type of patient would you expect to be on this type of diet?
A. A patient with heart disease
B. A patient with osteoporosis
C. A patient with Addison’s disease
D. A patient who recently had gastric bypass surgery
Answer: C
Patient’s with Addison disease secrete too much potassium so they need to be on a low potassium diet.
A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained and the results indicate a level of 0.6 ng/mL. The nurse determines that this result indicates which finding?
1. A normal level
2. A low value that indicates possible gastritis
3. A level that indicates a myocardial infarction
4. A level that indicates the presence of possible angina
Answer: 3
Rationale- Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL.
A labyrinthectomy can be performed to treat Meniere’s syndrome. This procedure results in:
A. Anosmia
B. Absence of pain
C. Reduction in cerumen
D. Permanent irreversible deafness
Answer: D
The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membranous semicircular canals. A labyrinthectomy is performed to alleviate the symptoms of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear
A client who is menopausal asks the nurse about the use of herbal therapy to treat hot flashes. Which of the following should the nurse recommend?
a. ginger root
b. black cohosh
c. saw palmetto
d. Kava
Answer: B
Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 inches (7.5 cm) in diameter and ½ inch (1.2 cm) deep around and under the lesion and left the wound open to heal. The wound will heal by:
A. primary intention.
B. secondary intention.
C. third intention.
D. tertiary intention.
Answer: B
A patient is admitted for diverticulitis. The patient has been on a full liquid diet and has been tolerating it well. Now the MD has ordered the patient a new diet. You would expect to find what type of food on the patient’s lunch tray?
A. Piece of white bread, skinless white potatoes, and white rice.
B. Glass of whole milk, broccoli, and cabbage
C. Peanut butter sandwich, glass of milk, and strawberries
D. French fries, chicken salad, and apple pie
Answer: A
Patients with diverticulitis should be started on a low-residue diet after full liquids have been tolerated. A piece of white bread, skinless white potatoes, and white rice are considered low-residue foods.
Which of the following adverse effects is specific to the biguanide diabetic drug metformin (Glucophage) therapy?
A. Hypoglycemia
B. GI distress
C. Lactic acidosis
D. Somnolence
Answer: C
Lactic acidosis is the most dangerous adverse effect of metformin administration with death resulting in approximately 50 percent of individuals who develop lactic acidosis while on this drug. Metformin does not induce insulin production; thus, administration does not result in hypoglycemic events. Some nausea, vomiting, and diarrhea may develop but is usually not severe. NVD is not specific for metformin. Metformin does not induce sleepiness.
The client is receiving an eye ointment and an eye drop. The nurse instructs the client to?
A. Administer the eye ointment first, followed by the eye drop.
B. Administer the eye drop first, followed by the eye ointment.
C. Administer the eye ointment, wait for 5 minutes then administer the eye drop.
D. Administer the eye drop, wait for 10 minutes then administer the eye ointment.
Answer: B
If both an eye drop and eye ointment are scheduled at the same time, administer the eye drop first; separate the installation by 3-5 minutes.
A client is trying to prevent complications of menopause such as osteoporosis and cardiovascular problems. Which intervention should the nurse suggest as most beneficial?
A. Weight-bearing exercise reduces the rate of bone loss and reduces cardiovascular risk.
B. Take 900 mg of calcium daily to prevent osteoporosis.
C. Black cohosh can reduce cardiovascular risk during menopause.
D. Hormone replacement therapy is essential for avoiding the complications of menopause.
Answer: A
Rationale: The nurse should emphasize the importance of weight-bearing exercise, which reduces the rate of bone loss, helps maintain optimum weight, and reduces cardiovascular risk. The recommended daily calcium intake for women over age 50 is 1200 mg to help prevent osteoporosis. While there are benefits to undergoing HRT, osteoporosis and cardiovascular problems are still possible. Researchers studying black cohosh, which is often used to treat hot flashes and other symptoms (not cardiovascular problems), have concluded that evidence for its effectiveness is lacking and further research is needed.
A 58 year old female is experiencing a flare-up with rheumatoid arthritis. While assisting the patient with her morning routine, the patient verbalizes a pain rating of 7 on 1-10 scale in the right and left wrist along with severe stiffness. You note the wrist joints to be red, warm, and swollen. What nonpharmalogical nursing interventions can you provide to this patient to help alleviate pain and stiffness? Select-all-that-apply:
A. Exercise the affected joints
B. Assist the patient with a warm shower or bath
C. Perform deep massage therapy to the wrist joints
D. Assist the patient with applying wrist splints
Answer: B & D
During flare-ups of RA the joint should be rested (not exercised) and should not be deep massaged because this can further damage the joint (in addition cause the patient more pain). Heat therapy, like a warm shower or bath, will help alleviate the stiffness. Furthermore, cold therapy can be used to reduce the inflammation along with splinting the affected joints to protect and rest them.