MED SURG FINAL EXAM 1 GRADED A+

MED SURG FINAL EXAM 1 [Document subtitle]   1. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? Irregular blue mole with white specks on the lower leg 2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?Change gloves between wound care on different parts of the client's body. 3. A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?Purulent drainage 4. A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut, limiting the client’s ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth. 5. A student nurse asks the nursing instructor what “apoptosis” means. What response by the instructor is best? Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition. 6. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? Use of multiple herbs and supplements 7. Which statement about carcinogenesis is accurate? Tumor cells need to develop their own blood supply. 8. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? Report of headache and stiff neck 9. The nurse caring for oncology clients knows that which form of metastasis is the most common? Bloodborne 10. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? "It helps prevent stomach ulcers, which are common after burns." 11. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? Encourage the client and family to be active partners. 12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? Place the client in an upright position. 13. A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? Use the Credé maneuver every 3 hours. 14. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client’s plan of care to prevent pressure sores? (Select all that apply.) Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the client's heels off the bed surfaces. 15. A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all that apply. Lesion with various colors Asymmetric 6-mm dark lesion on forehead 16. A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy. What action by the nurse is best? Coordinate continuation of the therapy. 17. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? Pain 18. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? Auscultate lung sounds. 19. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse take? Assess the IV site at least every 2 hours for thrombophlebitis. 20. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? Assess the right leg for pulses, skin color, and temperature 21. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg 22. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest. 23. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? Anxious client who has tachypnea 24. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client’s plan of care? (Select all that apply.) Height, Alcohol use, Prealbumin laboratory results 25. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? There are no distant metastases noted in the report. 26. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed 27. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?Severe osteoporosis 28. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching? "An advance directive will specify what I want done when I can no longer make decisions about health care." 29. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren’s syndrome? Visual acuity 30. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?Anal intercourse 31. A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below Punch skin biopsy 32. After educating a caregiver of a home care client, a nurse assesses the caregiver’s understanding. Which statement indicates that the caregiver needs additional education?" If his tailbone is red and tender in the morning, I will massage it with baby oil " 33. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?Assess the client's sexual activity and patterns. 34. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy?"Which method of contraception are you using?" 35. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale 36. A nurse identifies clinical practice problems on a cardiac unit. Which question is a background question? "How are a client's vital signs affected by anxiety? 37. After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client’s understanding. Which statement indicates the client has a good understanding of this condition? "I can use powder to keep this area dry." 38. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?" I'll cleanse the are prior to applying antibiotic cream " 39. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? Ensure the information is relayed to the surgical team. 40. A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? Creatinine of 3.9 mg/dL 41. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? Kussmaul respirations 42. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? Administer preoperative antibiotic as ordered. 43. A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? Hemoglobin and hematocrit 44. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? Potassium: 2.9 mEq/L 45. A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? Client with a white blood cell count of 23,000/mm3 46. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? "Being able to sleep doesn't mean pain doesn't exist." 47. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? Ice packs 48. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? Inform the surgeon that the sterile field has been broken 49. A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places the highest priority on interventions for which client problem? Potential for infection related to the site for organism invasion 50. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? Client with a respiratory rate of 6 breaths/min 51. The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? "Sometimes I wake up at night and smoke." 52. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Assisting the client to get out of bed to prevent falls, Obtaining a bedside commode if the client is weak, Providing gentle perianal cleansing after stools, Reporting any perianal abnormalities 53. A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? Don't make assumptions about their health needs. 54. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? “Have something to drink every 1 to 2 hours.” 55. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? Creatinine: 3.2 mg/dL 56. A medical-surgical nurse asks the nurse researcher, “What is the difference between qualitative and quantitative questions?” How should the nurse researcher respond? "Quantitative questions identify relationships between measurable concepts." 57. A nurse administers topical gentamicin sulfate (Garamycin) to a client’s burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? Creatinine 58. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? Apply oxygen by mask or nasal cannula 59. A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? Confirming placement of the catheter by x-ray 60. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) Constipation, Dehydration, Weakness 61. A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ Bone marrow 62. A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? Place the client on a cardiac monitor and pulse oximeter. 63. A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client’s risk of fracture? Perform weight-bearing activities. 64. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first Assess the client for adherence to the drug regimen. 65. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? Correctly identifying the client prior to a blood transfusion 66. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? Decreased orthostatic light-headedness and dizziness 67. A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? Fungal infection- Ketoconzole ( Nizoral ) 68. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? What medications are you taking? 69. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? Acetaminophen (Tylenol) 70. While assessing a client’s lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? Palpate the client’s pedal pulses bilaterally. 71. A nurse assesses an older adult client with the skin disorder shown below: Petechiae 72. While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous membranes. Which action should the nurse take next? Use pulse oximetry to assess the client's oxygen saturation 73. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? Consistent use of Standard Precautions 74. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? Instruct the client to call for help to get out of bed. 75. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3– 18 mEq/L. Which manifestation should the nurse identify as an example of the client’s compensation mechanism? Increased rate and depth of respirations EXAM 2 1. A patient comes to the health care provider’s office for an annual physical. The patient reports having a persistent, nagging cough. Which question does the nurse ask first about this symptom? “When did the cough start?” 2. When blood passes through the lungs, what happens to oxygen? It diffuses from the alveoli into the red blood cells. 3. Which substances from cigarette smoke have been implicated in the development of serious lung disease?(select all that apply) Nicotine, Tar, Carbon Monoxide 4. A patient reports smoking a pack of cigarettes a day for 9 years. He then quit for 2 years,and then smoked 2 packs a day for the last 30 years. What are the pack-years for this patient? 69 years 5. The nurse is providing care for a patient who would like to quit smoking. Which important teaching points must be included when teaching this patient?(select all that apply) Talk with your healthcare provider about nicotine replacement therapies, Ask for help from family and friends who have quit smoking, Remove all ashtrays, cigarettes, pipes, cigar, and lighters from your home to decrease the temptation to smoke. If you are used to having a cigarette after eating, get up from the table as soon as you are finished eating. 6. The patient is receiving oxygen at 5 L/min by nasal cannula. What priority intervention must the nurse use at this time? Humidify the oxygen with sterile water. 7. The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented x 3. What is the priority nursing action? Check the pulse oximeter reading 8. The nurse is caring for a patient receiving humidified oxygen. Which precaution does the nurse take to prevent bacterial contamination and infection? Always wear gloves when cleaning the patient’s nasal cannula 9. What is the best description of the nurse’s role in delivery of oxygen therapy? Being familiar with the devices and techniques used in order to provide proper care 10. A patient is receiving warmed and humidified oxygen. In discarding the moisture formed by condensation, why does the nurse minimize the time that the tubing is disconnected? To prevent the patient from desaturating 11. A patient is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other patients on the units have developed hospital- acquired infections and Pseudomonas aeruginosa has been identified as the organism. What does the nurse do? Change the humidifier every 24 hours 12. A patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long-term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session? Tracheostomy tube 13. A patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider? Skin is puffy at the neck with a crackling sensation 14. While the nursing student changes a patient’s tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4x4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse’s best action? Direct the student in the correct use of mater and explain the rationale. 15. A patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning? Hypoxia 16. A patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be more appropriate choice for this patient? Helps prevent drying damage to mucous membranes 17. A patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care? Uses oral swabs or a soft bristle brush moistened in water 18. The nurses is caring for a patient with a nasal fracture. The patient has clear secretions that react positively when tested for glucose. Which complication does the nurse suspect? Skull fracture 19. The patient with a nasal fracture has clear fluid draining from the nose which dries on a piece of filter paper and leaves a yellow “halo” ring at the dried edge of the fluid. What is the nurse’s best first action? Notify the healthcare provider 20. The nurse is caring for several patients who are at risk because of problems related to the upper airway. Which are the priority assessments and actions for these patients? Adequacy of oxygenation; ensure an unobstructed air passageway 21. On postoperative assessment, the nurse notes that the patient with a rhinoplasty repeatedly swallows. What is the nurse’s best first action? Examine the throat for bleeding 22. A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea? Side effects of hypoxemia, hypercapnia, and sleep deprivation 23. The patient with laryngeal trauma develops stridor. What is the nurse’s highest priority intervention? Call the Rapid Response Team 24. Which factors contributes to sleep apnea?(select all that apply) 25. The patient with laryngeal trauma develops stridor. What is the nurse’s highest priority intervention? Call the rapid response team 26. Which are characteristics of asthma?(select all that apply) Narrowed airway lumen due to inflammation, increased eosinophils, intermittent bronchospasm, situation of disease process by allergies. 27. The nurse is caring for an older adult patient with a chronic respiratory disorder. Which interventions are best to use in caring for this patient?(select all that apply) Provide rest periods between activities, schedule drug administration around routine activities, arrange chairs in strategic locations to allow patient to walk and rest, encourage the patient to have an annual flu vaccination. 28. An adult patient diagnosed with rhinitis medicamentosa reports chronic nasal congestion.What does the nurse instruct the patient to do? Discontinue the use of the current nose drop or sprays. 29. Which description best defines the cardiovascular concept afterload? Amount of pressure or resistance that the ventricles must overcome to eject blood through this semilunar valves and into the peripheral blood vessels 30. The nurse is providing health teaching for a patient at risk for heart disease. Which factor is the most modifiable, controllable risk factor? Obesity 31. Which statement about blood pressure are accurate? (Select all that apply) pulse pressure is the difference between the systolic and diastolic pressures, diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction, to maintain adequate blood flow to the coronary arteries mean arterial pressure must be at least 60 MM HG 32. Which category of cardiovascular drugs block the sympathetic stimulation to the heart and increase the heart rate? Beta blockers 33. What term describes the difference between systolic and diastolic values, which is an indirect measure of cardiac output? Pulse pressure 34. Patient comes to the clinic stating “ my right foot turns a darkish red color when i sit too long, and when i put my foot up, it turns pale.” Which conditions does the nurse suspect? Arterial insufficiency 35. The patient has smoked half a pack of cigarettes per day for two years. How many pack- years has this patient smoked? 36. In assessing a patient who has come to the clinic for a physical exam, the nurse sees that the patient has parlor. What is the find the most indicat in assessing a patient who has come to the clinic for physical exam, the nurse sees that the patient has pallor . What is the find the most indicative of? Anemia 37. The nurse is performing a cardiac assessment on older adults. What is a common assessment finding for this patient? S4 heart sound 38. A patient’s chart notes that the examiner has heard S1 and S2 auscultation of the heart. What does the documentation refer to? First and second heart sounds 39. The nurse is assessing a patient with suspected CVD. When assessing the precordium, which assessment technique does the nurse begin? Inspection 40. While listening to a patient's heart sounds, the nurse detects a murmur. What does the nurse understand about the cause of murmurs? A murmur is caused when there is turbulent blood flow through normal or abnormal valves 41. In assessing a patient, the nurse finds that the PMI appears in more than one intercostal space, and has shifted laterally to the midclavicular line. How does the nurse interpret this data? Left ventricular hypertrophy 42. The primary pacemaker of the heart, the SA node, is functional if a pt.s pulse is at what regular rate? 60 to 100 beats/min 43. What is the normal measurement of the PR interval in a ECG? 0.12-0.20 second 44. What is the QRS complex in an ECG normally? Less than 0.12 seconds 45. What is the ST segment in a ECG normally? Isoelectric 46. What is the total time required for ventricular depolarization and repolarization as represented on the ECG? QT interval 47. The nurses were viewing ECG results of a patient admitted for fluid and electrolyte in balances. The T waves are tall and peaked. The nurse reports this finding to the provider obtains an order for which Serum level test? Potassium 48. The nursing notified by the telemetry monitor technician about a patient’s heart rate. Which Method to confirm the technicians report? Assess the patient’s heart rate directly by taking apical pulse. 49. Atherosclerosis affects which large arteries? (select all that apply) 50. A patient is amid it with a vascular problem. Based on the pathophysiology of systemic arterial pressure, what is the systemic arterial pressure a product off?(select all that apply) cardiac output, peripheral vascular resistance 51. A patient is prescribed Atovastin(Lipitor). The nurse instructs the patient to watch for and report which side effect? Muscle cramps 52. A patient is prescribed Atovastin(Lipitor). The nurse instructs the patient to watch for and report which side effect? Muscle cramps 53. The nurse is reviewing the laboratory results hour urine test for a patient with a medical diagnosis of essential hypertension. The presence of catecholamines in the urine is evidence of which disorder? 54. Which are risk factors for hypertension?(select all that apply) 55. For which patient does the nurse question the use of hydrochlorothiazide? Patient with hypokalemia 56. Patient is undergoing diagnostic testing for pain and burning sensation in the legs. What does it ankle brachial index of less than 0.9 in either leg indicate? Presence of peripheral arterial disease 57. A patient has been admitted for acute angina. Which diagnostic test identifies of the patient will benefit from further invasive management after acute angina or an MI? Cardiac Catheterization 58. The nurse administers sublingual nitroglycerin to a patient experiencing angina episode. How soon does the nurse expect the painter begin to subside? 1-2 minutes 59. Which diagnostic test are used to assess myocardial damage caused by an MI? CK-MB isoenzymes elevation, Troponin I isoenzyme elevation 60. Which early reaction is most common in patients with the chest discomfort associated with unstable angina or MI? Denial 61. The nurse is performing hematologic assessment of an older adult patient. Which findings does the nurse identify as normal changes in the older adult? Progressive loss of body hair, thickened or discolored nails, Yellowing of the skin, Dryness of the skin 62. Which drug disrupts platelet action? Vitamin K 63. Severe anemia could cause enlargement of which organs? Liver 64. The student nurses care for a patient is sickle cell crisis. Which action by the student nurse warrants intervention by the supervisor nurse? Keep in a patient’s room cool 65. A patient scheduled to undergo diagnostic testing for sickle cell anemia. For which diagnostic test does the nurse provide patient teaching? Hemoglobin S 66. A patient has polycythemia Vera. Which action by the UAP requires intervention by the supervisor nurse? Assisting the patient floss his teeth 67. And caring for a patient with acute leukemia, what is the priority collaborative problem? Protecting the patient from infection 68. Which disorder is the highest risk for the patient to develop infection? Sickle cell crisis 69. The new registered nurse is getting a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse? “ I will complete replaceable transfusion within six hours“ 70. When caring for a patient at the bone marrow stem cell transplantation, when does the nurse expect engraftment to occur? 71. Which hematologic disorders most likely to cause a patient to have joint problems? Hemophilia 72. An older patient has been receiving frequent blood transfusions without any complications or adverse reactions; however, the nurse carefully monitor is the patient during the current transfusion. Which signs/symptoms suggest that the patient is experiencing circulatory overload? 73. The nurse is performing the immediate post procedure care for a bone marrow donor. What is the priority assessment that the nurse will perform? Monitor for infection 74. An older patient has been receiving frequent blood transfusions without any complications or adverse reactions; however, the nurse carefully monitor is the patient during the current transfusion. Which signs/symptoms suggest that the patient is experiencing circulatory overload? 75. The patient reports fatigue, bone pain, and frequent bacterial infections. Further investigation reveals anemia, hypercalcemia, X-Ray findings show bone thinning with areas of bone loss that resembles Swiss cheese. The signs/symptoms and diagnostic findings are consistent with which disorder? Multiple Myeloma EXAM 3 1. The nurse is assessing a clients abdomen. Identify the area where the nurse’s hand should be placed to palpate the liver. Upper Right Quadrant of Abdomen 2. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse preforms an assessment an assessment on the client, knowing that which symptoms is most indicative of this disorder? Polydipsia 3. Which client statement alerts the nurse to the possibility of hypothyroidism? “I am always tired even with 10 to 12 hours of sleep” 4. Which dietary modification does the nurse provide for a client with hyperthyrodism? Increased calories, proteins, and carbohydrates 5. Which client is at highest risk for hearing loss? A client with osteomyelitis receiving IV gentamicin (Garamycin) 6. A client’s chart indicate anisocoria. For what should the nurse assess? Difference in pupil size 7. The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone upon awakening in the morning. Which finding does the nurse expect to observe during the client’s physical assessment? Purulent fluid is present in the ear canal 8. The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? Heart rate and rhythm 9. Which nursing actions are appropriate following a liver biopsy? Select all that apply. Immediately assist client to turn on right side. Check vital signs every 10-15 minutes for 1-2 hours. Place a pillow under the right costal margin. Instruct the client to avoid heavy lifting for 1 week after biopsy. 10. A client is scheduled for an ultrasound to rule out bile duct obstruction. What preparation is required for an ultrasound test? Explanation about the procedure 11. Twelve hours after a total thyroidectomy, the client develops stridor. Which is the nurse’s priority intervention? Prepare for emergency tracheostomy and call the health care provider 12. What isolation precautions are necessary for a client with a history of hepatitis C who is “anti-HCV positive”? Standard precautions 13. The most important nursing assessment to make before a client is started on indomethacin is: Asking if there is a history of gastric bleeding 14. The nurse is caring for a client who has just been diagnosed with end-stage pancreatic cancer. The nurse assesses the client’s emotional response to the diagnosis. Which is the nurse’s initial action for the assessment? Determine whether the client feels like talking about his or her feelings. 15. Blood sugar management for a client who has Type 2 Diabetes with nausea and decreased appetite should include: Continuing insulin even if the client is vomiting 16. The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse’s best response? “Bile salts accumulate in the skin and cause the itching.” 17. The nurse is caring for a client with acute pancreatitis. During the physical assessment the nurse notes a grayish-blue discoloration of the client’s flanks. WHich is the nurse’s priority action? Ensure that the client has a patent large-bore IV site 18. What would be allowed in the diet of a client with Peptic Ulcer Disease (PUD)? Tomato juice 19. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplement? Hematocrit 31% 20. Which statement made by a diabetic client who has a urinary tract infection indicates that teaching was effective regarding antibiotic therapy? Even if I completely well, I should take the medication until it is gone.” 21. A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? Control hyperglycemia 22. A male client reports fluid secretion from his breasts. What does the nurse assess next in this client? Anterior pituitary hormones 23. THe nurse is obtaining the history of a client with a sliding hernia. Which symptoms does the nurse expect to see in this client? (Select all that apply) Belching, Dysphagia, reflux 24. The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life threatening complication may be developing, requiring notification of the health care provider immediately? Laryngeal stridor 25. The nurse notes a bulge in a client’s groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? Reducible inguinal hernia 26. A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? “I will not put my arms above my head.” 27. The nurse is caring for a client who is hospitalized with exacerbation of Crohn’s disease. What does the nurse expect to find during the physical assessment? High-pitched, rushing bowel sounds in the right lower quadrant 28. What is a common problem that older clients experience more frequently as they age? Decrease hydrochloric acid 29. The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse? Wash the hands when entering the room 30. A client is scheduled to receive Novolog insulin. When should it be administered? 15 minutes before the meal 31. A nurse instructs a client to eat a low-iodine diet before a thyroid study. A client should be told to avoid: Shellfish 32. A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? Begin a clear liquid diet 12 to 24 hours before the test 33. A client with a history of diabetes mellitus has new onset of microalbuminauria. Which component of the diet must the client reduce? Percentage of total calories derived from proteins 34. A client has hypothyroidism and has been started on levothyroxine (synthroid). Which assessment finding leads the nurse to conclude that the treatment is effective? Heart rate is 70 beats/min and regular 35. A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. Use all of the options. Ask the client to urinate. Auscultate the client’s abdomen. Percuss the client’s abdomen. Perform light palpation 36. The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? Runny nose 37. During assessment of a client with a 15 year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? Examine the client’s feet for signs of injury 38. An older client is being admitted to the hospital for pneumonia. The client has no other health problems. Which action by the nurse is best? Offer the client fluids every hour or two 39. A client has a hypofunctioning anterior pituitary gland. Which hormones does the nurse expect to be affected by this? (select all that apply) Thyroid-stimulating hormone, Follicle-stimulating hormone, Growth hormone 40. A client has a condition of excessive catecholamine release. Which assessment finding does the nurse correlate with this condition? Increased pulse 41. A nurse is caring for a female client with cholelithiasis. Which assessment findings from the client history and physical examination may have contributed to development of the condition? (select all that apply). Body mass index (BMI) of 46. Glycosylated hemoglobin level of 15%. Pregnant with twins. 42. A client who has been taking high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking corticosteroids. Which is the nurse’s best response? Once you start corticosteroids, you have to be weaned off them 43. A client receives a short-acting insulin and an intermediate-acting before breakfast at 0800. USing the chart below, when should the nurse expect the intermediate insulin to start to take effect? 1000 44. A client just diagnosed with acromegaly is scheduled for a hypophysectomy. Which statement made by the client indicates a need for clarification regarding this treatment? “I will drink whenever I feel thirsty after surgery.” 45. The nurse is preparing to administer tube feedings through a client’s new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? Obtain orders for a chest x-ray to confirm placement before starting the feeding 46. A client has been newly diagnosed with diabetes mellitus. Which statement made by the client indicates a need for further teaching regarding nutrition therapy? “I should try to keep my diet free from carbohydrates.” 47. The nurse is caring for a client who had undergone a Whipple procedure 2 days previously. THe nurse notes that the client’s hands and feet are edematous, and urine output has decreased from the previous day. Which intervention does the nurse expect to provide for the client? Add colloids to the client’s IV solutions 48. Which dietary alterations does the nurse make for a client with CUshing’s disease? Low carbohydrate, low sodium 49. Which assessment alerts the nurse to the possible presence of a cataract in a client? Blurred vision and reduced color perception 50. A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which is the nurse’s interpretation of these findings? Good control of blood glucose 51. A client has abnormal calcium levels. Which hormone does the nurse anticipate testing for? Thyrocalcitonin (calcitonin) 52. A nurse is assessing a client who had an esophagogastroduodenoscopy (EGD). THe first priority for the nurse should be: Monitoring or the return of the gag reflex 53. A client is being discharged after having a thyroidectomy. Which of the following discharge instructions would be appropriate for the client? Select all that apply Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician. Take thyroid replacement medication as ordered. 54. A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? On either side of the client 55. Which substance produced in the stomach facilitates the absorption of Vitamin B12? Intrinsic factor 56. A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? Assess and maintain a patent airway. 57. The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? No, in fact, your body mass index suggest that you are already underweight 58. The nurse is caring for a client with Menieres disease. The client asks the nurse how to prevent another acute episode from occuring. Which is the nurse’s best response? Stop or reduce cigarette smoking 59. Radioactive iodine is administered to a client with hyperthyroidism to: Limit secretion of thyroid hormone by destroying thyroid tissue 60. The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurse’s assessment findings will require collaboration with the client’s primary health care provider? Select all that apply Clear watery drainage is present in the ear canal and is positive for glucose. The client reports dizziness after taking naproxen (Aleve) for arthritis pain. Tympanic membrane is retracted, with multiple air bubbles. 61. The nurse conducts a physical assessment for a client with abdominal pain. WHich finding leads the nurse to suspect appendicitis? Severe, steady right lower quadrant (RLQ) pain 62. How does a tropic hormone differ from other hormones? Tropic hormones stimulate other endocrine glands to secrete hormones 63. A client with Crohn’s disease is scheduled to receive an infusion of infiximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? Checking the frequency and consistency of bowel movements 64. The nurse is caring for a client who is being discharged from the hospital after an attack of acute pancreatitis. Which discharge instructions does the nurse provide for the client to help prevent a recurrence? (selective all that apply) Attend local alcoholics anonymous (AA) meetings weekly. Use cooking spray when you cook rather than margarine or butter. We can talk to your doctor about a prescription for nicotine patches. 65. A client has been admitted to the emergency with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented on the chart below, the nurse would expect the client to have which diagnosis? Pancreatitis 66. On the second postoperative day after a subtotal thyroidectomy, the client tells the nurse that he feels numbness and tingling around his mouth. Which is the nurse’s priority intervention? Assess Chvostek’s sign 67. The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse’s priority action? Assess the client’s blood sugar 68. A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? Apply pressure to the inside corner of your eye when administering the drops. 69. A client with diabetes has a serum creatinine of 1.9 mg/dL. The nurse correlates which urinalysis finding with this client? Protein in the urine during a random urinalysis 70. The nurse reads on a client’s chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? Bulging eyes 71. A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse’s priority intervention? Monitor the apical pulse 72. The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the condition is chronic rather than acute? Clay-colored stools and dark amber urine 73. Which safety measure is most important for the nurse to institute for a client who has Cushings disease? Use a lift sheet to change the client’s position 74. Which situation of condition is likely to result in increased production of thyroid hormones? Starvation 75. A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? I will need to continue to watch my diet and may still need medication EXAM 4 1. During a neurologic assessment of a client, the nurse notes that the client’s arms, wrists, and fingers have become flexed, and an internal rotation plantar flexion of the legs are evident. How does the nurse document these findings? Decorticate posturing 2. The nurse is assessing a client with a spinal injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? Agitation and restlessness 3. A woman is being treated in the emergency department after being sexually assaulted. During the collection of evidence, the nurse prepares to collect toxicology from the client. The client questions why this is being done, as she has been the victim of an attack. What information can the nurse provide? The use of toxicology can assess if the woman was under the influence of drugs at the time of the assault. 4. Three weeks after developing acute renal failure (ARF) following trauma, the hospitalized client has a significantly increased urinary output. Which assessment finding should the nurse report to the health care provider immediately? A drop in BP and increase in pulse rate 5. The client, admitted to a surgical unit following a TURP, has a continuous bladder irrigation (CBI). The nurse assesses the client’s urine and finds dark red urine containing several small clots. Which intervention should the nurse implement? Increase the flow of the bladder irrigation 6. The nurse is assessing the client’s groin puncture site after a renal angiogram finds a saturated, bloody dressing and blood pooling on the sheets. What should be the nurse’s priority? Glove and apply firm pressure directly over the dressing 7. During a routine physical examination, a 22-year-old client reports she has recently had two relatives diagnosed with breast cancer. She questions which of her personal behaviors place her at risk for the development of the disease. Which of the following reported factors can be implicated in the increased risk for breast cancer? Onset of menarche at age 11 8. A client has reported to the emergency department with complaints of abdominal pain. After undergoing a series of test, the client has been diagnosed with pelvic inflammatory disease. The client becomes tearful and asks if this disease will make her unable to have children later. What response by the nurse is indicated? This disease is associated with infertility, but it is too early to know 9. A client is concerned about the risk of developing renal carcinoma. The nurse should respond by asking which of the following questions that would indicate the client may be at risk for developing renal carcinoma? Do you smoke cigarettes? 10. The nurse notes bright red blood and clots in the client’s urine after a cystoscopy. Which is the most appropriate initial action by the nurse? Notify the health care provider 11. A couple has come to the health care provider’s office with concerns about infertility. While collecting data, the woman questions the nurse about who is at fault for the inability to conceive. Which of the following statements by the nurse is most appropriate at this time? The causes of infertility are varied and will require further investigation 12. Which client does the nurse assess first at the start of the nursing shift? Client who reports increased pain and swelling after an arthroscopy 13. The nurse is planning care for the client who is scheduled for an IVP. Which intervention should the nurse plan to implement? Teach that a warm, flushing sensation may occur as the dye is injected 14. Which nursing intervention is most effective in preventing transfer of an organism from the wound of a client with osteomyelitis to other clients? Contact precautions 15. The client is hospitalized with nephrotic syndrome and has 3+ pitting edema in all extremities. Which laboratory test result should the nurse associate with this condition? Elevated protein in the urine 16. A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse’s first intervention? Assess pedal pulses 17. The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? Elevated acetylcholine receptor antibody levels 18. The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura? Visual disturbances 19. The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? Atrial fibrillation 20. The nurse is caring for a client with prostate cancer. Which laboratory finding indicated to the nurse that the cancer has metastasized to the bone? Serum calcium 21.6 mg/dL 21. The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse’s priority action? Turn the client’s head to the side. 22. The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? Reposition the client so that the reddened area does not bear weight 23. A client is having a routine prostate examination. An important question that the nurse would ask at this time is: “Do you have difficulty with urination?” 24. The nurse is caring for the client experiencing a possible hospital-acquired bladder infection. Which nursing action should the nurse perform first? Obtain a urine specimen for culture and sensitivity 25. During a routine physical examination, a 49-year-old patient voices concerns about developing BPH. He is interested in actions he can take to promote prostate health and potentially avoid the development of the disorder. What information can be provided to the patient? Encourage the patient to limit alcohol intake 26. The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action? Pale and cool to the touch 27. The nursing assistant reports that the client with chronic renal failure (CRF) has “white crystals” and dry, itchy skin. Based on this information, which instruction should the nurse give to the nursing assistant? Prepare a tepid-water bath for the client 28. Which instruction does the nurse give to the client before he or she has electromyography (EMG)? “Do not take your cyclobenzaprine (Flexeril) on the 2 days before the test.” 29. A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? Lorazepam (Ativan) 30. The nurse is caring for a client receiving hemodialysis. Which of the following assessments would be necessary to detect complications of disequilibrium syndrome? Level of consciousness 31. An older woman is admitted after falling down the stairs. Which assessment findings require immediate intervention?(Select all that apply) Potassium 6.0 mEq/L, Dark brown urine, blood pressure 80/50 mm Hg 32. A client who has been experiencing dysmenorrhea has come to the ambulatory care clinic. The health care provider has diagnoses the presence of endometriosis. The client asks how this condition is responsible for her pain. What information should be included in the teaching provided? The endometrial tissue located outside of the uterus responds to the hormones responsible for the menstrual period. 33. A 32-year-old African American woman has just been diagnosed with uterine fibroid tumors. The woman is upset and has several questions about the condition. After providing education to her, the nurse will recognize the need for further education when the woman makes which of the following statements? The growth of my tumors is directly linked to my progesterone levels 34. The nurse is performing a medical history and physical assessment on an older client. Which common findings in the older client are related to the musculoskeletal system? (Select all that apply) Decrease in bone density, Atrophy of the muscle tissue, Reduced range of motion of the joints, Degeneration of cartilage 35. The nurse is caring for four clients. Which client requires further nursing assessment due to the risk of prerenal failure? The client who has congestive heart failure 36. A patient reports to the emergency department with complaints of scrotal swelling. During the assessment, the patient reports his pain level at “2”. When asked to discuss the characteristics of his pain, he reports feeling a dull ache associated with prolonged standing or walking. The physical assessment reveals a “bag of worms” appearance to the scrotum. Which of the following disorders is likely presented? Varicocele 37. Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? Respiratory pattern and airway 38. After performing a physical assessment on a 75- year old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client’s plan of care? Assist the client with ambulation 39. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe? Memory loss 40. The nurse is caring for a client following a knee arthroscopy. What information should the nurse teach? Select all that apply Elevate the involved extremity on pillows for 24-48 hours, report severe joint pain immediately to the health care provider, treat pain with a mild analgesic such as acetaminophen 41. The nurse is assessing the client receiving peritoneal dialysis. Which finding suggests that the client may be developing peritonitis? Cloudy dialysis output. 42. A client who experienced a spinal cord injury 1 year ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client. Methylprednisolone (Medrol) 43. Which postoperative order does the nurse clarify with the surgeon before discharging the client who just had an arthroscopic surgery on the right knee? Administer two tablets of oxycodone/APAP (Tylox) every 4 hours for pain 44. A chronic renal failure client is exhibiting signs of metabolic acidosis. Upon assessment of the client’s respiratory status, the nurse would expect: Kussmaul respirations 45. The wife of a man diagnosed with prostate cancer appears disheveled and anxious during her visit to her husband. When the patient leaves the floor for testing, the nurse uses the opportunity to approach her. Which of the following approaches by the nurse is most therapeutic? Would you like to talk about your concerns? 46. The nurse is admitting a hospitalized client who has a renal calculi. Which should be the nurse’s priority? Assess the location and the severity of the client’s pain 47. The nurse is caring for a client with a fractured femur. Which factor in the client’s history may impede healing of the fracture? Paget’s disease 48. The nurse is caring for several clients with fractures. Which client does the nurse consider at highest risk for developing deep vein thrombosis? Older man who smokes and has a fractured pelvis 49. A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action? The traction weights are resting on the floor. 50. The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see? Bilateral hypoactive reflexes 51. The client is being assessed for rotator cuff injury. Which physical assessment finding is consistent with this type of injury? The client is unable to initiate or maintain abduction of the affected arm at the shoulder 52. A client admitted the previous day for a suspected neurologic disorder becomes increasinglly lethargic. Which is the best nursing action? Complete a full neurologic assessment and notify the neurologist 53. A 19-year-old patient presents to the emergency department with complaints of testicular inflammation and pain. Laboratory tests are performed. Which of the following results is consistent with the suspected diagnosis of orchitis? WBC: 14,500/mm 54. The client has a newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis. Which interventions should the nurse plan to implement. Select all that Apply Tell the nursing assistant to take the BP on the right arm, Palpate for a thrill over the left forearm fistula, Check left radial pulse, finger movement, and sensation, Instruct about the hand exercises that start in a week 55. During a neurologic examination, a client demonstrates a positive Romberg’s sign with eyes closed, but not with eyes open. Which condition does the nurse associate with this finding? Difficulty with proprioception 56. The nurse is rounding on assigned orthopedic clients. The client with which type of fracture requires immediate interventions to prevent infection? Open fracture of the tibia 57. A 20-year-old client is being seen at the health care provider’s office for an annual physical examination. During the data collection period, the client indicates she does not believe she is old enough to be concerned about performing a breast self-examination. What information should be provided to the client? Women should begin to perform a monthly breast self- examination by the age of 20 58. The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barre syndrome? The immune system destroys the myelin sheath 59. The clinic nurse is reviewing the history of the client diagnosed with bacterial vaginosis (BV). Which identified disorder places the client at a higher risk for developing BV? Diabetes Mellitus 60. Laboratory testing is ordered for a 61-year-old patient suspected of having prostatitis. Which of the following procedures will likely be included? Urinalysis 61. The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? Wear your brace when you are out of bed 62. A client has been diagnosed with carpal tunnel syndrome. Which intervention does the nurse question in the treatment of this injury? Morphine 30 mg to be taken orally every 4 hours 63. A 75 year old client is hospitalized with ESRD. Which finding in the client’s medical record should the nurse associate with the diagnosis of ESRD? A glomerular filtration rate less than 15 mL/min/1.73m2 64. A nursing home resident returns to the facility after receiving a hemodialysis treatment. Which symptom observed by the charge nurse suggests that the client has developed disequilibrium syndrome? Headache with a decreased level of consciousness 65. The nurse is caring for the female client experiencing recurrent UTIs. Which statement would best help the client reduce her risk for another UTI? Eliminate caffeine and tea from your diet 66. A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse’s best response? Please come to the clinic today to have your arm checked by the healthcare provider 67. The nurse is assigned to provide care for a client who had laparoscopy performed to determine the extent of her endometriosis. Which of the findings in the first 4 hours after the procedure by the nurse will indicate the need to contact the health care provider? Restlessness 68. A male client states that he is having problems with impotence. Which of the following diseases should the nurse question as part of the client’s past medical history? Select All that Apply Hypertension, Alcoholism, Diabetes 69. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse plan to see? Impaired Judgement 70. A client is admitted with acute glomerulonephritis. The nurse inspects the clients urine and expects to find: Tea- colored urine 71. The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? Controllable facial twitching 72. A woman reports to the health care provider with complaints of urinary incontinence and abdominal/ pelvic pressure. The health care provider examines the patient and diagnoses her condition as a cystocele. Upon hearing the diagnosis, the patient reports that she has heard about this condition. When receiving education about the condition, she states she is relieved the condition is only the result of the weakening of the structures that support her uterus. What response by the nurse is indicated? The cystocele has occured because the bladder is pressing downward on the uterus 73. The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse? Numbness and tingling in the extremity 74. The health care provider prescribes cyclobenzaprine (flexeril) 30 mg orally TID for the client hospitalized with acute cervical neck pain. The pharmacy supplied 10 mg tablets. Which action by the nurse is best? Call the health care provider to question the dose prescribed 75. The nurse is caring for the client who had continent urinary diversion surgery with creation of a kock pouch. Which intervention should the nurse include in the care? Insert a catheter in the pouch every 4 to 6 hours to drain the urine 76. The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nuree? I am unable to urinate 77. A 40-year-old client undergoes a total abdominal hysterectomy. After the procedure, the patient voices an interest in hormone replacement therapy. What information should be provided to the client? Hormone replacement therapy is not indicated after this particular procedure 78. The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority? Sensation and pulse of the right forearm 79. A female client is experiencing hot flashes. The client asks the nurse how long will these last. The nurse would respond by stating that hot flashes: May last up to 5 years 80. A 44-year-old man has sought treatment for erectile dysfunction. The patient asks specifically to be considered for sildenafil (Viagra) therapy. Which of the following factors in the patient’s medical history must be taken into consideration for this particular medication? Select all that Apply The patient has angina, The patient has a history of hypotension 81. During a routine breast examination of a client, the nurse notes a small amount of nipple discharge. The