Concept 1 Adaptive Quizzing Physiological Integrity

Concept 1 Adaptive Quizzing Physiological Integrity 1. A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply. 1Dry skin 2Slow pulse 3Weight gain Correct4Nervousness Correct5Increased appetite Nervousness is associated with hyperthyroidism because of central nervous system irritation. The appetite increases with hyperthyroidism because of the increased metabolic rate. Moist skin occurs with hyperthyroidism because of the increase in the metabolic rate. Dry skin occurs with hypothyroidism because of the decrease in the metabolic rate. Tachycardia occurs with hyperthyroidism because of the increase in the metabolic rate. Bradycardia occurs with hypothyroidism because of the decrease in the metabolic rate. Weight loss occurs with hyperthyroidism because of the increase in the metabolic rate. Weight gain occurs with hypothyroidism because of the decrease in the metabolic rate. 2. A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. 1Crackles Correct2Cyanosis 3Wheezing Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign. 3. What clinical findings should lead a nurse to suspect that a toddler with a rash has rubella? Select all that apply. 1Conjunctivitis 2Nuchal rigidity Correct3Low-grade fever Correct4Lymphadenopathy 5Koplik spots in the mouth Low-grade fever, malaise, sneezing, and coughing characterize rubella. Lymphadenopathy, especially of the posterior cervical and periauricular nodes, characterizes rubella. Conjunctivitis occurs with measles (rubeola), not rubella. Nuchal rigidity is associated with meningitis and encephalitis, not with rubella. Koplik spots are present with rubeola, not rubella. 4. The nurse is teaching a nursing student how to care for a client who underwent stereotactic radiosurgery for a pituitary adenoma. Which statement made by the student indicates effective learning? 1"I will assess for bleeding." 2"I will monitor cardiac output." Correct3"I will monitor serum osmolarity." 4"I will assess for glucose levels in nasal discharge." A client who underwent stereotactic radiosurgery for a pituitary adenoma may experience transient diabetes insipidus. Thus serum and urine osmolarity should be closely monitored. Bleeding is a complication caused by hypophysectomy. Cardiac output should be monitored in clients who underwent thyroid surgery because they may experience hypothyroidism post-surgery. High glucose levels in nasal discharge may indicate meningitis in a client who underwent a hypophysectomy for pituitary adenoma. 5. A 4-year-old child with nephrotic syndrome has repeated relapses. As the child gets older, what is the most important attribute for the child to develop? Correct1 A positive body image 2 The ability to test urine 3 Fine muscle coordination 4 Acceptance of possible sterility Children with nephrotic syndrome are treated with immunosuppressive agents, including steroids. During exacerbations they may have a characteristic pale, overweight appearance as a result of edema. Steroid side effects include growth retardation, cataracts, obesity, and hirsutism. Children may become very sensitive about these changes as they grow older. Although the ability to test the urine may be indicated, body image poses a greater concern. Engaging in usual childhood activities between attacks should promote the development of fine muscle coordination. Sterility is not associated with nephrotic syndrome. 6. What are the treatment goals in anorexia nervosa? Select all that apply. 1The development of a calorie-restricted diet plan 2The development of a regular exercise schedule Correct3The repairing of family interactions Correct4The reinstitution of normal nutrition to counteract a state of malnutrition Correct5The correction of deficits and distortions in psychological functioning via psychotherapy Clients with anorexia nervosa have a strong fear of becoming overweight. This is characterized by reduced nutritional food intake causing progressive weight loss and malnutrition. These clients usually have impaired family interactions due to low self-esteem. Therefore, the treatment goals should consist of repairing family interactions, reinstituting normal nutritional meals, and correcting deficits and distortions in psychological functioning. 7. The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? Select all that apply. 1Arrange for restorative care. Correct2Help the family set up home care if required. 3Refrain from telling the family that the client is dying. Because some dying clients prefer to be at home with the family during their last days, the nurse should help the family set up home care if required. The nurse should also know the client and family well to be able to provide client-centered care. The nurse should also arrange for church or community support to help the client and family during this difficult time. A dying client may be in pain and require hospice care, not restorative care. The nurse must maintain the trust in the nurse-client relationship and prepare the family for the client’s death. The nurse should inform the family about the dying process. 8. A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? Correct1Depression 2Dependency 3Marital stress 4Identity confusion Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression. 9. When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? 1Stating, "You must take your medicine now." Correct2Saying, "I’ll be back in a few minutes so we can talk." 3Explaining why it is necessary to take the medication 4Withholding the medication before notifying the primary healthcare provider Saying, "I’ll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept logical explanations when angry. Alternative nursing interventions should be attempted before withholding the medication and notifying the primary healthcare provider, although these may become necessary. 10. A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? 1Loss of appetite 2Postural hypotension 3Total memory loss Correct4Confusion immediately after the treatment The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is usually restored after a few months of treatment. 11. A nurse is interviewing a client with the diagnosis of dementia of the Alzheimer type. What question should the nurse ask to assess the client’s orientation to place? Correct1"Where are you?" 2"Who brought you here?" Incorrect3"Do you know where you are?" 4"How long have you been here?" "Where are you?" is the best question with which to elicit information about the client’s orientation to place, because it encourages a response that can be assessed. Asking who brought the client focuses on recent memory; it does not assess orientation to place. "Do you know where you are?" can be answered yes or no and will not objectively reveal the client’s orientation. "How long have you been here?" focuses on orientation to time, not place. 12. An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 lb (9.1 kg) in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention? 1Complimenting the physical appearance of the adolescent 2Explaining the value of adequate nutrition to the adolescent 3Exploring the reasons that the adolescent does not want to eat Correct4Attempting to establish a trusting relationship with the adolescent The problem is psychological. Therefore the nurse’s initial approach should be directed toward establishing trust. The client is convinced about being overweight; complimenting the client will not change self-perception. The client is not ready for nutrition information. Exploring the reasons that the adolescent does not want to eat may be appropriate after trust has been established. 13. An adolescent on the psychiatric unit has an angry outburst toward another client who cut in front of people standing in line to get their mail. Later the nurse conducts a one-on-one therapeutic session with the angry client. What is an appropriate short-term goal for the client to strive for? 1Continuing to vent angry feelings Correct2Talking about the situation that precipitated the anger 3Apologizing for the angry outburst in the community meeting 4Asking for a prescribed medication for when feelings of anger begin Talking about the episode may help the client gain insight into the behavior. This is essential before control strategies can be developed. Continuing to vent angry feelings is inappropriate and may escalate the angry behavior. Apologizing for the angry outburst in the community meeting may humiliate the client. The client should apologize to the individual involved; the outburst was directed at another client, not at the entire inpatient community. Asking for a prescribed as- needed medication will interfere with development of the ability to appropriately discharge angry feelings; medications may be used on an as-needed basis if the client is losing control and at risk for injuring someone else. 14. A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense mechanism is the client using when identifying the other clients? Correct1Splitting 2Ambivalence 3Passive aggression 4Reaction formation Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. Ambivalence is the experience of feeling opposite emotions at the same time. Passive aggression is the expression of hostility toward another in an indirect, nonassertive way. Reaction formation is the expression of unacceptable desires by adopting opposite behaviors in an exaggerated way. 15. A client with schizophrenia, paranoid type, is delusional, withdrawn, and negativistic. What should the nurse plan to do? Correct1Invite the client to play a game of cards or board game. 2Explain to the client the benefits of joining a group activity. 3Encourage the client to become involved in group activities. 4Mention to the client that the primary healthcare provider has prescribed increased activity. Activities that require limited interpersonal contact are less threatening. Individuals with schizophrenia, paranoid type, usually do not respond to an authoritarian approach, because they do not trust others, particularly those who act in an aggressive manner. Group activities require interaction with other people, which is threatening to individuals with paranoid feelings. 16. The mother of a 7-month-old infant who is to be catheterized to obtain a sterile urine specimen expresses fear that this procedure may emotionally traumatize her baby. How should the nurse respond? 1"I’ll obtain a clean-catch specimen instead." 2"You have a legal right to refuse the catheterization." Correct3"The procedure will not be emotionally traumatic at this age." 4"Your child’s catheterization takes priority over your concern." A 7-month-old infant is used to having the perineal area exposed and cared for and is not in a developmental stage in which fears related to sexuality are present, thus the procedure will not be emotionally traumatic for the child. A clean- catch specimen at this age may be contaminated. The order is for a catheterized specimen. Although the mother does have the right to refuse, her concern is not realistic for an infant at this age. The mother needs to be educated. The priority is assuring the mother that a catheterization will not result in an emotional problem for her infant. 17. A child with sickle cell disease experiences a sequestration crisis. The parents ask how it differs from a painful episode (vaso-occlusive crisis). What is the best response by the nurse? 1Peripheral ischemia occurs along with the pain. Correct2Blood volume decreases and signs of shock appear. Incorrect3Red blood cell (RBC) production diminishes with severe anemia. 4Destruction of RBCs is accelerated and jaundice becomes evident. In this type of episode there is pooling of blood in the liver and spleen, with subsequent decreased circulating blood volume and shock. Peripheral ischemia, along with the pain, is characteristic of a vaso-occlusive crisis. Decreased RBC production and the profound anemia that ensues are characteristics of aplastic crisis. Increased hemolysis and concomitant anemia, jaundice, and reticulocytosis are characteristics of hyperhemolytic crisis. 18. What are the clinical manifestations of actinic keratosis in a client? Select all that apply. 1Firm, nodular lesions Correct2Small papules with dry skin Correct3Wrinkled, weather-beaten skin 4Pearly papules with a central crater 5Irregularly shaped, pigmented papule Small papules with dry skin and wrinkled, weather-beaten skin are clinical manifestations of actinic keratosis. Firm, nodular lesions are clinical manifestations of squamous cell carcinoma. Pearly papules with a central crater are the clinical manifestations of basal cell carcinoma. Irregularly shaped, pigmented papules are the clinical manifestations of melanoma. 19. A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply. 1Jaundice Correct2Boardlike abdomen