A male client with a cerebellar brain tumor is admitted to an acute care facility. The
nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase
should the nurse add to complete the nursing diagnosis statement?
A. Related to visual field deficits
B. Related to difficulty swallowing
C. Related to impaired balance
D. Related to psychomotor seizures
Give this one a try later!
, Answer: C
Explanation: A client with a cerebellar brain tumor may suffer injury from
impaired balance as well as disturbed gait and incoordination. Visual field
deficits, difficulty swallowing, and psychomotor seizures may result from
dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or
temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing
suggests medullary dysfunction. Psychomotor seizures suggest temporal
lobe dysfunction.
Which intervention is appropriate for the nurse caring for a male client in severe pain
receiving a continuous I.V. infusion of morphine?
A. Assisting with a naloxone challenge test before therapy begins
B. Discontinuing the drug immediately if signs of dependence appear
C. Changing the administration route to P.O. if the client can tolerate fluids
D. Obtaining baseline vital signs before administering the first dose
Give this one a try later!
Answer: D
Explanation: The nurse should obtain the client's baseline blood pressure
and pulse and respiratory rates before administering the initial dose and
then continue to monitor vital signs throughout therapy. A naloxone
challenge test may be administered before using a narcotic antagonist, not
a narcotic agonist. The nurse shouldn't discontinue a narcotic agonist
abruptly because withdrawal symptoms may occur. Morphine commonly is
used as a continuous infusion in clients with severe pain regardless of the
ability to tolerate fluids.
Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention
for his comfort?
A. Give tepid baths
B. Avoid lotions and creams
C. Use hot water to increase vasodilation
D. Use cold water to decrease the itching
,Give this one a try later!
Answer: A
Explanation: For pruritus, care should include tepid sponge baths and use
of emollient creams and lotions
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and
requires paracentesis. Relief of which symptom indicated that the paracentesis was
effective?
A. Pruritus
B. Dyspnea
C. Jaundice
D. Peripheral Neuropathy
Give this one a try later!
Answer: B
Explanation: Ascites puts pressure on the diaphragm. Paracentesis is done
to remove fluid and reducing pressure on the diaphragm. The goal is to
improve the patient's breathing. The others are signs of cirrhosis that aren't
relieved by paracentesis
Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings
do you expect to be abnormal for this patient?
A. Serum creatinine and BUN
B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
C. Serum amylase and lipase
D. Cardiac enzymes
Give this one a try later!
Answer: C
Explanation: Pancreatitis involves activation of pancreatic enzymes, such as
, amylase and lipase. These levels are elevated in a patient with acute
pancreatitis.
The nurse is admitting a male client with laryngeal cancer to the nursing unit. The
nurse assesses for which most common risk factor for this type of cancer?
A. Alcohol abuse
B. Cigarette smoking
C. Use of chewing tobacco
D. Exposure to air pollutants
Give this one a try later!
Answer: B
Explanation: The most common risk factor associated with laryngeal cancer
is cigarette smoking. Heavy alcohol use and the combined use of tobacco
increase the risk. Another risk factor is exposure to environmental
pollutants.
A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching the
client how to care for the neck stoma, the nurse should include which instruction?
A. "Keep the stoma uncovered."
B. "Keep the stoma dry."
C. "Have a family member perform stoma care initially until you get used to the
procedure."
D. "Keep the stoma moist."
Give this one a try later!
Answer: D
Explanation: The nurse should instruct the client to keep the stoma moist,
such as by applying a thin layer of petroleum jelly around the edges,
because a dry stoma may become irritated. The nurse should recommend
placing a stoma bib over the stoma to filter and warm air before it enters
nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase
should the nurse add to complete the nursing diagnosis statement?
A. Related to visual field deficits
B. Related to difficulty swallowing
C. Related to impaired balance
D. Related to psychomotor seizures
Give this one a try later!
, Answer: C
Explanation: A client with a cerebellar brain tumor may suffer injury from
impaired balance as well as disturbed gait and incoordination. Visual field
deficits, difficulty swallowing, and psychomotor seizures may result from
dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or
temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing
suggests medullary dysfunction. Psychomotor seizures suggest temporal
lobe dysfunction.
Which intervention is appropriate for the nurse caring for a male client in severe pain
receiving a continuous I.V. infusion of morphine?
A. Assisting with a naloxone challenge test before therapy begins
B. Discontinuing the drug immediately if signs of dependence appear
C. Changing the administration route to P.O. if the client can tolerate fluids
D. Obtaining baseline vital signs before administering the first dose
Give this one a try later!
Answer: D
Explanation: The nurse should obtain the client's baseline blood pressure
and pulse and respiratory rates before administering the initial dose and
then continue to monitor vital signs throughout therapy. A naloxone
challenge test may be administered before using a narcotic antagonist, not
a narcotic agonist. The nurse shouldn't discontinue a narcotic agonist
abruptly because withdrawal symptoms may occur. Morphine commonly is
used as a continuous infusion in clients with severe pain regardless of the
ability to tolerate fluids.
Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention
for his comfort?
A. Give tepid baths
B. Avoid lotions and creams
C. Use hot water to increase vasodilation
D. Use cold water to decrease the itching
,Give this one a try later!
Answer: A
Explanation: For pruritus, care should include tepid sponge baths and use
of emollient creams and lotions
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and
requires paracentesis. Relief of which symptom indicated that the paracentesis was
effective?
A. Pruritus
B. Dyspnea
C. Jaundice
D. Peripheral Neuropathy
Give this one a try later!
Answer: B
Explanation: Ascites puts pressure on the diaphragm. Paracentesis is done
to remove fluid and reducing pressure on the diaphragm. The goal is to
improve the patient's breathing. The others are signs of cirrhosis that aren't
relieved by paracentesis
Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings
do you expect to be abnormal for this patient?
A. Serum creatinine and BUN
B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
C. Serum amylase and lipase
D. Cardiac enzymes
Give this one a try later!
Answer: C
Explanation: Pancreatitis involves activation of pancreatic enzymes, such as
, amylase and lipase. These levels are elevated in a patient with acute
pancreatitis.
The nurse is admitting a male client with laryngeal cancer to the nursing unit. The
nurse assesses for which most common risk factor for this type of cancer?
A. Alcohol abuse
B. Cigarette smoking
C. Use of chewing tobacco
D. Exposure to air pollutants
Give this one a try later!
Answer: B
Explanation: The most common risk factor associated with laryngeal cancer
is cigarette smoking. Heavy alcohol use and the combined use of tobacco
increase the risk. Another risk factor is exposure to environmental
pollutants.
A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching the
client how to care for the neck stoma, the nurse should include which instruction?
A. "Keep the stoma uncovered."
B. "Keep the stoma dry."
C. "Have a family member perform stoma care initially until you get used to the
procedure."
D. "Keep the stoma moist."
Give this one a try later!
Answer: D
Explanation: The nurse should instruct the client to keep the stoma moist,
such as by applying a thin layer of petroleum jelly around the edges,
because a dry stoma may become irritated. The nurse should recommend
placing a stoma bib over the stoma to filter and warm air before it enters
