A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency?
K

Feedback:
Clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.

Based on the analysis of the client’s atrial fibrillation, the nurse should prepare the client for which treatment protocol?
Anticoagulation therapy.

Feedback:
The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?
Nocturia

Feedback:
As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia

A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?
Start an IV nitroglycerin infusion.

Feedback:
Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol

The nurse is completing an admission interview and assessment on a client with a history of Parkinson’s disease. Which question should provide information relevant to the client’s plan of care?
Have you ever been ‘frozen’ in one spot, unable to move?

Feedback:
Clients with Parkinson’s disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move

The nurse is assessing a client who has a history of Parkinson’s disease for the past 5 years. What symptoms should this client most likely exhibit?
Shuffling gait, masklike facial expression, and tremors of the head.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion?
Pain in the calf upon exertion which is relieved by rest and elevating the extremity.

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement?
Question the healthcare provider’s prescription

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
The test you are having tomorrow requires that you have nothing by mouth tonight.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client’s willingness to become compliant with the prescribed diet?
He visits his diabetic brother who just had surgery to amputate an infected foot.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information is most useful to the nurse when planning activities for the group?
The usual activity patterns of each member of the group.

A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
Collect further data to determine whether self-neglect is occurring.

The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care?
Risk for injury related to denial of deficits and impulsiveness.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client?
Advise the client to remain in bed with the leg elevated.

Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system?
Increased heart rate.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client’s
temperature.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client’s joints?
Initiate a weight-reduction diet to achieve a healthy body weight.

In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger’s disease (thromboangiitis obliterans), which referral is most important?
Smoking cessation program.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?
Inflammatory with peau d’orange.

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
Purulent sputum.

Which postmenopausal client’s complaint should the nurse refer to the healthcare provider?
Episodes of vaginal bleeding.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
Sudden, stabbing, severe pain over the lip and chin.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
Raising the head of the bed on blocks.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
Perform a breast self-exam (BSE) procedure monthly.

During lung assessment, the nurse places a stethoscope on a client’s chest and instructs him/her to say “99” each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words “99” very clearly through the stethoscope?
May indicate pneumonia.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A) Cyanosis of the fingertips.
B) Bradycardia and bradypnea.
C) Presence of S3 and S4 heart sounds.
D) 3+ pitting edema of the lower extremities.
A) Cyanosis of the fingertips.
Feedback: CORRECT
Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands

A client who is receiving chemotherapy asks the nurse, “Why is so much of my hair falling out each day?” Which response by the nurse best explains the reason for alopecia?
A) Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.
B) Alopecia is a common side effect you will experience during long-term steroid therapy.
C) Your hair will grow back completely after your course of chemotherapy is completed.
D) The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss.
A) Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.
Feedback: CORRECT
The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy’s effect on the rapidly reproducing cells, both normal and malignant

What discharge instruction is most important for a client after a kidney transplant?
A) Weigh weekly.
B) Report symptoms of secondary Candidiasis.
C) Use daily reminders to take immunosuppressants.
D) Stop cigarette smoking.
C) Use daily reminders to take immunosuppressants.
Feedback: CORRECT
After renal transplantation, acute rejection is a risk for several months, so immunosuppressive therapy, such as corticosteroids and azathioprine (Imuran), is essential in preventing rejection, so the priority instruction includes measures, such as daily reminders, to ensure the client takes these medications regularly.

During an interview with a client planning elective surgery, the client asks the nurse, “What is the advantage of having a preferred provider organization insurance plan?” Which response is best for the nurse to provide?
A) Long-term relationships with healthcare providers are more likely.
B) There are fewer healthcare providers to choose from than in an HMO plan.
C) Insurance coverage of employees is less expensive to employers.
D) An individual can become a member of a PPO without belonging to a group.
C) Insurance coverage of employees is less expensive to employers.
Feedback: CORRECT
The financial advantage of (C) is the feature of a PPO that is most relevant to the average consumer. The nurse must have knowledge about PPOs, which provide discounted rates to large employers who provide insurance coverage for their employees. In return, the insurance company receives a large pool of clients for their facilities.

Small bowel obstruction is a condition characterized by which finding?
A) Severe fluid and electrolyte imbalances.
B) Metabolic acidosis.
C) Ribbon-like stools.
D) Intermittent lower abdominal cramping.
A) Severe fluid and electrolyte imbalances.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information is most useful to the nurse when planning activities for the group?
A) The length of time each group member has resided at the nursing home.
B) A brief description of each resident’s family life.
C) The age of each group member.
D) The usual activity patterns of each member of the group.
D) The usual activity patterns of each member of the group.
Feedback: CORRECT

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
C) Skin pigmentation and hair texture for evidence of hormonal changes.
D) Previous birth-control methods and beliefs about the calendar method.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
Feedback: CORRECT

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day.
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake.
B) Increase intake of soluble fiber to 10 to 25 grams per day.
Feedback: CORRECT

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?
A) Osteoporosis is a progressive genetic disease with no effective treatment.
B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
C) Estrogen replacement therapy should be started to prevent the progression osteoporosis.
D) Low-dose corticosteroid treatment effectively halts the course of osteoporosis.
B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
Feedback: CORRECT

Based on the analysis of the client’s atrial fibrillation, the nurse should prepare the client for which treatment protocol?
A) Diuretic therapy.
B) Pacemaker implantation.
C) Anticoagulation therapy.
D) Cardiac catheterization.
C) Anticoagulation therapy.
Feedback: CORRECT

The nurse is assessing a client who has a history of Parkinson’s disease for the past 5 years. What symptoms should this client most likely exhibit?
A) Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
B) Shuffling gait, masklike facial expression, and tremors of the head.
C) Extreme muscular weakness, easy fatigability, and ptosis.
D) Numbness of the extremities, loss of balance, and visual disturbances.
B) Shuffling gait, masklike facial expression, and tremors of the head.
Feedback: CORRECT

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client’s joints?
A) Increase the amount of calcium intake in the diet.
B) Apply alternating heat and cold therapies.
C) Initiate a weight-reduction diet to achieve a healthy body weight.
D) Use a walker for ambulation to lessen weight-bearing on the hips.
C) Initiate a weight-reduction diet to achieve a healthy body weight.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
A) She sustained an insect bite to her left arm yesterday.
B) She has lost twenty pounds since the surgery.
C) Her healthcare provider now prescribes a calcium channel blocker for hypertension.
D) Her hobby is playing classical music on the piano.
A) She sustained an insect bite to her left arm yesterday.
Feedback: CORRECT

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
A) A 35-year-old multipara who never breastfed.
B) A 50-year-old whose mother had unilateral breast cancer.
C) A 55-year-old whose mother-in-law had bilateral breast cancer.
D) A 20-year-old whose menarche occurred at age 9.
B) A 50-year-old whose mother had unilateral breast cancer.
Feedback: CORRECT
The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms?
A) Loss of thirst, weight gain.
B) Dependent edema, fever.
C) Polydipsia, polyuria.
D) Hypernatremia, tachypnea.
A) Loss of thirst, weight gain.

Feedback: CORRECT
SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D).

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of “heart trouble,” but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?
A) Ask the client what he means by “heart trouble.”
B) Call for an ECG to be performed immediately.
C) Notify surgery that the ECG is over two years old.
D) Notify the client’s surgeon immediately.
B) Call for an ECG to be performed immediately.

Feedback: CORRECT
Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (B) should be implemented to ensure that the client’s current cardiovascular status is stable. Additional data might be valuable (A), but since time is limited, the priority is to obtain the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (D).

22.
Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?
A) Describe proper administration of vaginal suppositories and cream.
B) Encourage the client to perform Kegel exercises 10 times daily.
C) Explain the importance of using condoms when having sexual intercourse.
D) Discuss the importance of keeping a diary of daily temperature and menstrual cycle events.
B) Encourage the client to perform Kegel exercises 10 times daily.

Feedback: CORRECT
Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis. (B) helps strengthen the surrounding muscles. Medication will not help correct a cystocele, rectocele, or uterine prolapse (A). (C) will help prevent sexually transmitted diseases. (D) is used to identify fertile times during the woman’s menstrual cycle.

A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
A) Notify social services immediately of suspected elderly abuse.
B) Discuss the need for mental health counseling with the daughter.
C) Explain to the client that she needs to take better care of herself.
D) Collect further data to determine whether self-neglect is occurring.
D) Collect further data to determine whether self-neglect is occurring.

Feedback: CORRECT
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed (D) before notifying social services (A) or discussing a need for counseling (B). Until further information is obtained, explanations about the client’s needs are premature (C).

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?
A) Stage II.
B) Invasive infiltrating ductal carcinoma.
C) T1N0M0.
D) Inflammatory with peau d’orange.
D) Inflammatory with peau d’orange.

Feedback:
Inflammatory breast cancer, which has a thickened appearance like an orange peel (peau d’orange), is the most aggressive form of breast malignancies (D). Staging classifies cancer by the extension or spread of the disease, and (A) indicates limited local spread. (B) indicates cancer cells have spread from the ducts into the surrounding breast tissue only. TNM classification is used to indicate the extent of the disease process according to tumor size, regional spread lymph nodes involvement, and metastasis, and (C) indicates early cancer with small in situ involvement, no lymph node involvement, and no distant metastases.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion?
A) Pain in the calf awakening him from a sound sleep.
B) Calf pain on exertion which stops when standing in one place.
C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
D) Pain upon arising in the morning which is relieved after some stretching and exercise.
C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity.

Feedback: CORRECT
Thrombophlebitis pain is relieved by rest and elevation of the extremity (C). It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place (B). (A and D) describe pain that is not common with thrombophlebitis.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?
A) Vasodilators and hormones.
B) Analgesics and sedatives.
C) Anticoagulants and expectorants.
D) Bronchodilators and steroids.
D) Bronchodilators and steroids.

Feedback: CORRECT
Besides supplemental oxygen, the ARDS client needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, i.e., bronchodilators and steroids (D). (A) would not help the condition. (B) would further depress the client and compromise the ability to breathe. Anticoagulants would be contraindicated since clotting of the blood is not yet a problem, and expectorants are not appropriate for this critically ill client (C).

A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?
A) Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).
B) Getting pregnant while using an IUD is common and is not the best contraceptive choice.
C) Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission.
D) Selecting a contraceptive device should consider choosing a successful method used in the past.
A) Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).

Feedback: CORRECT
The use of an IUD provides the client with no protection from STDs (A). While pregnancy rates with the use of an IUD are somewhat higher, (B) is not therapeutic, but judgmental. (C) is judgmental and does not provide the client any information about use of an IUD. While talking about contraceptives may include (D), it is does not provide the best information to maintain the client’s health.

The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client’s
A) serum digoxin level is 1.5.
B) blood pressure is 104/68.
C) serum potassium level is 3.
D) apical pulse is 68/min.
C) serum potassium level is 3.

Feedback:
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement?
A) Administer 30 minutes before eating.
B) Evaluate the effectiveness 1 hour after administration.
C) Instruct the client to swallow the tablet whole.
D) Question the healthcare provider’s prescription.
D) Question the healthcare provider’s prescription.

Feedback: CORRECT
Magnesium agents are not usually used for clients with renal failure due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse (D). (A, B, and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox).

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client’s medication record. Which medication is most likely the cause of the bradycardia?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex).
A) Propanolol (Inderal).
Feedback: CORRECT
Feedback:
Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate.

A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement?
A) Review the electrocardiogram tracing.
B) Obtain blood for coagulation studies.
C) Apply a warming blanket.
D) Provide heated PO fluids.
A) Review the electrocardiogram tracing.

Feedback:
Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous cardiac monitoring is indicated (A) because hypothermic clients have an increased risk for dysrhythmias. Coagulations studies (A) and re-warming procedures (C and D) can be initiated after a review of the ECG tracing (A).

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion?
A) Pain in the calf awakening him from a sound sleep.
B) Calf pain on exertion which stops when standing in one place.
C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
D) Pain upon arising in the morning which is relieved after some stretching and exercise.
C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity.

Feedback:
Thrombophlebitis pain is relieved by rest and elevation of the extremity (C). It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place (B). (A and D) describe pain that is not common with thrombophlebitis.

The nurse formulates the nursing diagnosis of, Urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement?
A) Teach the client techniques of intermittent self-catheterization.
B) Decrease fluid intake to prevent over distention of the bladder.
C) Use incontinence briefs to maintain hygiene with urinary dribbling.
D) Explain that anticholinergic drugs will decrease muscle spasticity.
A) Teach the client techniques of intermittent self-catheterization.

Feedback:
Bladder control is a common problem for clients with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization (A) to prevent bladder distention. Adequate hydration, not (B), is important to reduce the risk of urinary tract infections by promoting elimination which reduces the time microorganisms spend in the bladder and by diluting the number of microorganisms in the bladder. Self-catheterization helps prevent dribbling, so (C) is unnecessary. Cholinergic drugs improve bladder muscle tone and help with bladder emptying, not (D).

Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system?
A) Pupil constriction.
B) Increased heart rate.
C) Bronchial constriction.
D) Decreased blood pressure.
B) Increased heart rate.

Feedback:
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a flight-or-fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system.

The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide?
A) This recessive disorder is carried only on the X chromosome.
B) Occurrences mainly affect males and heterozygous females.
C) Both genes of a pair must be abnormal for the disorder to occur.
D) One copy of the abnormal gene is required for this disorder.
C) Both genes of a pair must be abnormal for the disorder to occur.

Feedback:
Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A and B) dominant or recessive disorder or an autosomal dominant inheritance disorder. Both genes of a pair, not (D), must be present.

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?
A) Notify the healthcare provider for reinsertion.
B) Attempt to reinsert the tracheostomy tube.
C) Position the client in a lateral position with the neck extended.
D) Ventilate client’s tracheostomy stoma with a manual bag-mask.
B) Attempt to reinsert the tracheostomy tube.

Feedback:
The nurse should attempt to reinsert the tracheostomy tube (B) by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed. (A, C, and D) place the client at risk of airway obstruction.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?
A) Osteoporosis is a progressive genetic disease with no effective treatment.
B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
C) Estrogen replacement therapy should be started to prevent the progression osteoporosis.
D) Low-dose corticosteroid treatment effectively halts the course of osteoporosis.
B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.

Feedback:
Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can prevent further bone loss (B). Osteoporosis can be managed with conservative therapy, such as bone metabolism regulators and estrogen replacement therapy (ERT) to improve bone density, but it is not a genetic disease (A). Although ERT is effective in managing osteoporosis, an increased risk for cancer and heart disease should be considered for individual clients. Corticosteroid therapy promotes bone resorption and is counterproductive in maintaining or increasing bone density (D).

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client’s willingness to become compliant with the prescribed diet?
A) He visits his diabetic brother who just had surgery to amputate an infected foot.
B) He is provided with the most current information about the dangers of untreated diabetes.
C) He comments on the community service announcements about preventing complications associated with diabetes.
D) His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.
A) He visits his diabetic brother who just had surgery to amputate an infected foot.

Feedback:
The loss of a limb by a family member (A) will be the strongest event or “cue to action” and is most likely to increase the perceived seriousness of the disease. (B, C, and D) may influence his behavior but do not have the personal impact of (A).

The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care?
A) Impaired physical mobility related to right-sided hemiplegia.
B) Risk for injury related to denial of deficits and impulsiveness.
C) Impaired verbal communication related to speech-language deficits.
D) Ineffective coping related to depression and distress about disability.
B) Risk for injury related to denial of deficits and impulsiveness.

Feedback:
With right-brain damage, a client experience difficulty in judgment and spatial perception and is more likely to be impulsive and move quickly, which placing the client at risk for falls (B). Although clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical impairments on the contralateral side of the body, not the same side (A). The client with a left-brain injury may manifest right-sided hemiplegia with speech or language deficits (C). A client with left-brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D).

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
A) A 35-year-old multipara who never breastfed.
B) A 50-year-old whose mother had unilateral breast cancer.
C) A 55-year-old whose mother-in-law had bilateral breast cancer.
D) A 20-year-old whose menarche occurred at age 9.
B) A 50-year-old whose mother had unilateral breast cancer.

Feedback:
The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause. Although all of the women described have one of the risk factors for developing breast cancer, (B) has the greater risk over (A, C, and D).

When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?
A) A diet low in phosphates.
B) Skin inspection for bruising.
C) Exercise regimen, including swimming.
D) Elimination of hazards to home safety.
D) Elimination of hazards to home safety.

Feedback:
Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures can be given (D). A low phosphorus diet is not recommended in the treatment of osteoporosis (A). Bruising (B) is not a related symptom to osteoporosis. Weight-bearing exercise is most beneficial for clients with osteoporosis. Swimming (C) is not a weight-bearing exercise.

Which client should the nurse recognize as most likely to experience sleep apnea?
A) Middle-aged female who takes a diuretic nightly.
B) Obese older male client with a short, thick neck.
C) Adolescent female with a history of tonsillectomy.
D) School-aged male with a history of hyperactivity disorder.
B) Obese older male client with a short, thick neck.

Feedback:
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client?
A) Apply sequential compression devices (SCDs) bilaterally.
B) Assess for a positive Homan’s sign in each leg.
C) Pad all bony prominences on the affected leg.
D) Advise the client to remain in bed with the leg elevated.
D) Advise the client to remain in bed with the leg elevated.
Feedback:
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care includes bedrest and elevation of the extremity (D). SCDs are used to prevent thrombophlebitis, not for treatment, when a clot might be dislodged (A). Once a client has thrombophlebitis, (B) is contraindicated because of the possibility of dislodging a clot. (C) is indicated to prevent pressure ulcers, but is not a therapeutic action for thrombophlebitis.

A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?
A) Determine the client is anxious and allow him to sleep.
B) Evaluate his blood pressure, pulse, and respiratory status.
C) Review the client’s pre-operative history for alcohol abuse.
D) Continue to monitor the client for reactivity to anesthesia.
B) Evaluate his blood pressure, pulse, and respiratory status.

Feedback:
Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client’s vital signs (B) will provide information about possible cardiovascular complications, such as stroke. The client’s anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated to the client’s sudden onset of slurred speech.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
A) Tinnitus, vertigo, and hearing difficulties.
B) Sudden, stabbing, severe pain over the lip and chin.
C) Facial weakness and paralysis.
D) Difficulty in chewing, talking, and swallowing.
B) Sudden, stabbing, severe pain over the lip and chin.

Feedback:
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) (B). (A) would be characteristic of Méniére’s disease (8th cranial nerve). (C) would be characteristic of Bell’s palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal cranial nerve (12th).

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy?
A) An increase in abdominal girth.
B) Hypertension and a bounding pulse.
C) Decreased bowel sounds.
D) Difficulty in handwriting.
D) Difficulty in handwriting.

Feedback:
A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level which is the primary cause of hepatic encephalopathy.

The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client’s wound is infected.
D) If the client’s wound is infected.

Feedback:
Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most important to place an infected client in a private room (D). A penrose drain does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a dead space and is not important in choosing a room.

A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
A) Notify social services immediately of suspected elderly abuse.
B) Discuss the need for mental health counseling with the daughter.
C) Explain to the client that she needs to take better care of herself.
D) Collect further data to determine whether self-neglect is occurring.
D) Collect further data to determine whether self-neglect is occurring.

Feedback:
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed (D) before notifying social services (A) or discussing a need for counseling (B). Until further information is obtained, explanations about the client’s needs are premature (C).

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?
A) Muscle weakness.
B) Urinary frequency.
C) Abnormal involuntary movements.
D) A decline in cognitive function.
A) Muscle weakness.

Feedback:
Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and are manifested by muscle weakness (A) and wasting. ALS does not manifest (B and C). In ALS, the client remains cognitively intact, not (D), while the physical status deteriorates.

Which assessment finding by the nurse during a client’s clinical breast examination requires follow-up?
A) Newly retracted nipple.
B) A thickened area where the skin folds under the breast.
C) Whitish nipple discharge.
D) Tender lumpiness noted bilaterally throughout the breasts.
A) Newly retracted nipple.

Feedback:
A newly retracted nipple (A), compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up. The inframammary ridge (B) is a normal anatomic finding. Up to 80% of women may experience an intermittent nipple discharge (C), especially related to recent stimulation, and in most cases, nipple discharge is not related to malignancy. (D) is a classic finding for fibrocystic breast disease, a benign condition.

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?
A) 15 minutes before and 15 minutes after the next dose.
B) One hour before and one hour after the next dose.
C) 5 minutes before and 30 minutes after the next dose.
D) 30 minutes before and 30 minutes after the next dose.
C) 5 minutes before and 30 minutes after the next dose.

Feedback:
Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.

In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger’s disease (thromboangiitis obliterans), which referral is most important?
A) Genetic counseling.
B) Twelve-step recovery program.
C) Clinical nutritionist.
D) Smoking cessation program.
D) Smoking cessation program.

Feedback:
Buerger’s disease is strongly related to smoking. The most effective means of controlling symptoms and disease progression is through smoking cessation (D). The cause of Buerger’s disease is unknown; a genetic predisposition is possible, but (A) will not be of value. The client with Buerger’s disease does not need referral to a 12-step program any more than the general population (B). Diet is not a significant factor in the disease, and general healthy diet guidelines can be provided by the nurse (C).

Which information about mammograms is most important to provide a post-menopausal female client?
A) Breast self-examinations are not needed if annual mammograms are obtained.
B) Radiation exposure is minimized by shielding the abdomen with a lead-lined apron.
C) Yearly mammograms should be done regardless of previous normal x-rays.
D) Women at high risk should have annual routine and ultrasound mammograms.
C) Yearly mammograms should be done regardless of previous normal x-rays.

Feedback:
The current breast screening recommendation is a yearly mammogram after age 40 (C). Breast self-exam (A) continues to be a priority recommendation for all women because a small lump (or tumor) is often first felt by a woman before a mammogram is obtained. The radiation exposure from a mammogram is low, so (B) is not normally provided. The frequency of using routine and ultrasound mammograms (D) in women with high-risk variables, such as a history of breast cancer, the presence of BRC1 and BRC2 genes, or 2 first-degree relatives with breast cancer, should be recommended and followed closely by the healthcare provider.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
A) Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
B) Purse the lips while inhaling as deeply as possible and then exhale through the nose.
C) Wrap a towel around the abdomen and push against the towel while forcefully exhaling.
D) Place one hand on the chest, one hand the abdomen and make both hands move outward.
A) Place a small book or magazine on the abdomen and make it rise while inhaling deeply.

Feedback:
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so (A) helps the client visualize the rise and fall of the abdomen. The client should purse the lips while exhaling, not (B). (C and D) are ineffective.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
A) Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line.
B) Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line.
C) Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder.
D) Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
D) Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.

Feedback:
In MCL I monitoring, the positive electrode is placed on the client’s mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest (D). The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. (A, B, and C) describe incorrect placement of electrodes for telemetry monitoring.

While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?
A) Immediately after the exposure.
B) Within one week of the exposure.
C) Four to six weeks after the exposure.
D) Three months after the exposure.
C) Four to six weeks after the exposure.

Feedback:
A tuberculin skin test is effective 4 to 6 weeks after an exposure (C), so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test.

A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
A) Position the head of the bed (HOB) flat.
B) Withhold intravenous fluids.
C) Administer a bolus of IV fluids.
D) Give an antihypertensive medications.
D) Give an antihypertensive medications.

Feedback:
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, the client’s current elevated blood pressure requires antihypertensive medication (D). Positioning the HOB flat (A) decreases venous drainage and contributes to cerebral edema post stroke. Increased blood viscosity during sleep may be related to reduced fluids, so (B) is not indicated. Increasing the vascular fluid volume increases the blood pressure, so (C) is not indicated.

The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide?
A) This recessive disorder is carried only on the X chromosome.
B) Occurrences mainly affect males and heterozygous females.
C) Both genes of a pair must be abnormal for the disorder to occur.
D) One copy of the abnormal gene is required for this disorder.
C) Both genes of a pair must be abnormal for the disorder to occur.

Feedback:
Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A and B) dominant or recessive disorder or an autosomal dominant inheritance disorder. Both genes of a pair, not (D), must be present.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?
A) Stay out of direct sunlight.
B) Restrict intake of high protein foods.
C) Schedule extra rest periods.
D) Go to the emergency room immediately.
C) Schedule extra rest periods.

Feedback:
Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. Extra rest periods should be scheduled (C) to reduce the symptoms. (A, B, and D) are not necessary.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength.
A) Prevention of deformities.

Feedback:
Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.

The nurse is assessing a client’s laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
A) Serum PTT of 10 seconds.
B) Serum calcium of 5 mg/dl.
C) Oxygen saturation of 90%.
D) Hemoglobin of 10 g/dl.
B) Serum calcium of 5 mg/dl.

Feedback:
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS.

A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse recommend the client return for repeat blood testing?
A) 6 to 18 months.
B) 1 to 12 months.
C) 1 to 18 weeks.
D) 6 to 12 weeks.
D) 6 to 12 weeks.
Feedback:
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to repeat the serum screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests positive. (B and C) may provide inaccurate results because the time frame maybe too early to reevaluate the client.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?
A) Fluid and electrolyte balance.
B) Prevention of water toxicity.
C) Reduced glucose in the urine.
D) Adequate cellular nourishment.
D) Adequate cellular nourishment.

Feedback:
Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy, so the outcome statement should include stabilization of adequate cellular nutrition (D). (A, B, and C) relate to subsequent osmolar fluid shifts related to glucosuria, polyuria, and polydipsia.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse’s assessment of the client is most likely to reveal which sign/symptom?
A) Leukocytosis and febrile.
B) Polycythemia and crackles.
C) Pharyngitis and sputum production.
D) Confusion and tachycardia.
D) Confusion and tachycardia.

Feedback:
The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?
A) Muscle weakness.
B) Urinary frequency.
C) Abnormal involuntary movements.
D) A decline in cognitive function.
A) Muscle weakness.

Feedback:
Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and are manifested by muscle weakness (A) and wasting. ALS does not manifest (B and C). In ALS, the client remains cognitively intact, not (D), while the physical status deteriorates.

The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A) Increased WBC, decreased RBC.
B) Increased serum bilirubin, slightly increased liver enzymes.
C) Increased protein in the urine, slightly increased serum glucose levels.
D) Decreased serum sodium, an increased urine specific gravity.
C) Increased protein in the urine, slightly increased serum glucose levels.

Feedback:
In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.

A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse’s response to the client should be based on which information?
A) The vaccine is given annually before the flu season to those over 50 years of age.
B) The immunization is administered once to older adults or persons with a history of chronic illness.
C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.
D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years.
B) The immunization is administered once to older adults or persons with a history of chronic illness.

Feedback:
It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re-vaccination is sometimes required.

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding should the nurse expect this client to exhibit?
A) A decreased total lung capacity.
B) Normal arterial blood gases.
C) Normal skin coloring.
D) An absence of sputum.
C) Normal skin coloring.

Feedback:
The differentiation between the “pink puffer” and the “blue bloater” is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations) (C). Total lung capacity is increased in emphysema since these clients have hyperinflated lungs (A). Arterial blood gases are typically abnormal (B). (D) is indicative of bronchitis, while clients with emphysema usually have copious amounts of thick, white sputum.

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
A) Listen to bilateral lung and bowel sounds.
B) Obtain the client’s pulse and blood pressure.
C) Assist the client to the bathroom to void.
D) Check the client’s gag and swallow reflexes.
D) Check the client’s gag and swallow reflexes.

Feedback:
Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway’s protective reflexes, gag and swallow reflexes, have returned (D). (A, B, and C) are not the priority before reintroducing oral fluids after a gastroscopy.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
A) Tinnitus, vertigo, and hearing difficulties.
B) Sudden, stabbing, severe pain over the lip and chin.
C) Facial weakness and paralysis.
D) Difficulty in chewing, talking, and swallowing.
B) Sudden, stabbing, severe pain over the lip and chin.

Feedback:
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) (B). (A) would be characteristic of Méniére’s disease (8th cranial nerve). (C) would be characteristic of Bell’s palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal cranial nerve (12th).

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy?
A) An increase in abdominal girth.
B) Hypertension and a bounding pulse.
C) Decreased bowel sounds.
D) Difficulty in handwriting.
D) Difficulty in handwriting.

Feedback:
A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level which is the primary cause of hepatic encephalopathy.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?
A) Maintain the residual limb on three pillows at all times.
B) Place a large tourniquet at the client’s bedside.
C) Apply constant, direct pressure to the residual limb.
D) Do not allow the client to lie in the prone position.
B) Place a large tourniquet at the client’s bedside.

Feedback:
A large tourniquet should be placed in plain sight at the client’s bedside (B). If severe bleeding occurs, the tourniquet should be readily available and applied to the residual limb to control hemorrhage. The residual limb should not be placed on a pillow (A) because a flexion contracture of the hip may result. (C) should be avoided because it may compromise wound healing. (D) should be encouraged to stretch the flexor muscles and to prevent flexion contracture of the hip.

Which milestone indicates to the nurse successful achievement of young adulthood?
A) Demonstrates a conceptualization of death and dying.
B) Completes education and becomes self-supporting.
C) Creates a new definition of self and roles with others.
D) Develops a strong need for parental support and approval.
B) Completes education and becomes self-supporting.

Feedback:
Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay.

During an interview with a client planning elective surgery, the client asks the nurse, “What is the advantage of having a preferred provider organization insurance plan?” Which response is best for the nurse to provide?
A) Long-term relationships with healthcare providers are more likely.
B) There are fewer healthcare providers to choose from than in an HMO plan.
C) Insurance coverage of employees is less expensive to employers.
D) An individual can become a member of a PPO without belonging to a group.
C) Insurance coverage of employees is less expensive to employers.

Feedback:
The financial advantage of (C) is the feature of a PPO that is most relevant to the average consumer. The nurse must have knowledge about PPOs, which provide discounted rates to large employers who provide insurance coverage for their employees. In return, the insurance company receives a large pool of clients for their facilities. (A, B, and D) are not accurate representations of the PPO.

Which client should the nurse recognize as most likely to experience sleep apnea?
A) Middle-aged female who takes a diuretic nightly.
B) Obese older male client with a short, thick neck.
C) Adolescent female with a history of tonsillectomy.
D) School-aged male with a history of hyperactivity disorder.
B) Obese older male client with a short, thick neck.

Feedback:
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A) Cyanosis of the fingertips.
B) Bradycardia and bradypnea.
C) Presence of S3 and S4 heart sounds.
D) 3+ pitting edema of the lower extremities.
A) Cyanosis of the fingertips.

Feedback:
Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands (A) which may lead to gangrene. (B, C, and D) are abnormal findings, but do not indicate the development of septic emboli.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?
A) Present knowledge related to the skill of injection.
B) Intelligence and developmental level of the client.
C) Willingness of the client to learn the injection sites.
D) Financial resources available for the equipment.
C) Willingness of the client to learn the injection sites.

Feedback:
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching (C). To determine learning needs, the nurse should assess (A), but this is not the most important factor for the nurse to assess. (B and D) are factors to consider, but not as vital as (C).

The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?
A) Safety precautions during activity.
B) Assess for changes in size of lymph nodes.
C) Maintain a fluid intake of 3 to 4 L per day.
D) Administer narcotic analgesic around the clock.
C) Maintain a fluid intake of 3 to 4 L per day.

Feedback:
Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight bearing (A) should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal complications. (B) is a component of ongoing assessment. Chronic pain management (D) should be included in the plan of care, but prevention of complications related to hypercalcemia is most important.

In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)
A) Set the infusion pump to infuse the albumin within four hours.
B) Compare the client’s blood type with the label on the albumin.
C) Assign a UAP to monitor blood pressure q15 minutes.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.
A) Set the infusion pump to infuse the albumin within four hours.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.

Feedback:
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin administration does not require blood typing (B). Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding (F).

A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?
A) Avoid high carbohydrate foods.
B) Decrease intake of fat soluble vitamins.
C) Decrease caloric intake.
D) Restrict salt and fluid intake.
D) Restrict salt and fluid intake.

Feedback:
Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not impact fluid retention.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?
A) Present knowledge related to the skill of injection.
B) Intelligence and developmental level of the client.
C) Willingness of the client to learn the injection sites.
D) Financial resources available for the equipment.
C) Willingness of the client to learn the injection sites.

Feedback:
If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching (C). To determine learning needs, the nurse should assess (A), but this is not the most important factor for the nurse to assess. (B and D) are factors to consider, but not as vital as (C).

A client who is HIV positive asks the nurse, “How will I know when I have AIDS?” Which response is best for the nurse to provide?
A) Diagnosis of AIDS is made when you have 2 positive ELISA test results.
B) Diagnosis is made when both the ELISA and the Western Blot tests are positive.
C) I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister?
D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.
D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.

Feedback:
AIDS is diagnosed when one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (D) (PCP, candidacies, crytpococcus, cryptosporidiosis, Kaposi’s sarcoma, CNS lymphomas). (A and B) identify the presence of HIV, indicating a high probability that in time the individual will develop AIDS, but do not necessarily denote the presence of AIDS. (C) is telling the client how he/she feels (afraid) and is dismissing the situation to the minister. This client is asking a question and specific medical information needs to be provided.

Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious in an elderly person because
A) elderly persons usually live alone and cannot summon help when symptoms appear.
B) elderly persons are more likely to eat high-fat diets which make them susceptible to heart disease.
C) cardiac symptoms, such as confusion, are more difficult to recognize in the elderly.
D) elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls.
D) elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls.

Feedback:
Cardiac output is decreased with aging (D). Because of loss of contractility and elasticity, blood flow is decreased and tachycardia is poorly tolerated. Therefore, if an elderly person experiences dysrhythmia (tachycardia or bradycardia), further compromising their cardiac output, they are more likely to experience syncope, falls, transient ischemic attacks, and possibly dementia. Most elderly persons do not eat high-fat diets (B) and most are not confused (C). Although many elderly persons do live alone, inability to summon help (A) cannot be assumed.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?
A) A history of obesity.
B) An allergy to sulfa drugs.
C) Cessation of smoking three years ago.
D) Numbness in the soles of the feet.
B) An allergy to sulfa drugs.

Feedback:
An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider. (A) is common and warrants counseling, but does not have the importance of (B). (C) does increase the risk for vascular disease, but it is not as important to the treatment regimen as (B). Diabetic neuropathy, as indicated by (D), is common with diabetics, but when the serum glucose is decreased, new onset numbness can possibly improve.

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client’s complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
C) Premenstrual syndrome.
D) Chronic use of laxatives.
B) Inability to get pregnant.

Feedback:
Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility.

A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client?
A) Impaired communication related to paralysis of skeletal muscles.
B) High risk for infection related to increased intracranial pressure.
C) Potential for injury related to impaired lung expansion.
D) Social isolation related to inability to communicate.
A) Impaired communication related to paralysis of skeletal muscles.

Feedback:
To increase the client’s tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C).

While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take?
A) Notify respiratory therapy immediately for a PRN bronchodilator treatment.
B) Obtain a prescription to increase the tidal volume setting on the ventilator.
C) Stop mechanical ventilation and re-assess the client’s lung sounds bilaterally.
D) Suction the client’s endotracheal tube and auscultate following suctioning.
D) Suction the client’s endotracheal tube and auscultate following suctioning.

Feedback:
Coarse, snoring sounds (rhonchi) heard over large upper airways are frequently produced by secretions partially blocking air passages and usually disappear after suctioning (D). (A) is indicated for a bronchospasm, which typically produces wheezing or musical adventitious lung sounds. Increasing the tidal volume (B) does not help resolve the problem. Mechanical ventilators produce noise that makes lung auscultation difficult, but removal of the ventilator to listen to breath sounds (C) is contraindicated, as this may reduce oxygenation. Category: Medical-Surgical

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome?
A) Carotid stenosis.
B) Steatosis hepatitis.
C) Metastatic cancer.
D) Clavicular fracture.
C) Metastatic cancer.

Feedback:
Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer (C) from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. (A, B, and D) do not result in SVC syndrome.

A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the HCP? Lung Tissue Biopsy (http://en.wikipedia.org/wiki/Sarcoidosis) A 58y/o client who has been post-menopausal for 5 years is concerned …

The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations the client is likely to experience? “Have you ever been ‘frozen’ in one spot, unable to move? A female …

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should …

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A) Tinnitus, vertigo, and hearing difficulties. B) Sudden, stabbing, severe pain over the lip and chin. C) Facial weakness and paralysis. D) Difficulty in chewing, …

what is the best response by the nurse? “select whatever day you can best remember to perform BSE consistently each month.” what instructions should the nurse provide? “when you are lying down, your arm should be positioned over your head.” …

The nurse is caring for a client who was medicated for pain 1 hour ago. The client states that the medication is not working and the pain is still present. What is the first action that the nurse will take? …

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