Med-Surg HESI Final Practice Questions Answers

Med-Surg HESI Final Practice Questions Answers Which 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 - After a renal transplantation, acute rejection is a high risk for several months. The organ recipient will have to take immunosuppressive therapy for the rest of their lives, such as corticosteroids and azathioprine, to prevent organ transplant rejection. Discharge instructions include measures such as daily reminders to ensure the client takes these medications regularly to prevent organ rejection from occurring. 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 - To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would 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 - For a client exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility, the initial care includes bedrest and elevation of the extremity. 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 - The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease. 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 - 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 help prevent further bone loss. 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. Which 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 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 - There are different recommendations from different agnecies. For a client with no risk factors, the earliest breast screening recommendation is a yearly mammogram at the age 40 and till the age of 54. After that every two years. The American College of OB/GYN still recommend starting mammograms starting at the age of 40 and yearly screeenings. The American Cancer Society new guidelines recommend starting at the age of 45 and thereafter till the age of 54 years old, then every two years. The US Preventive Services Task Force Services (USPSTS) recommends starting at the age of 50 years old and screenings every two years thereafter. The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? A. Flush the tube with 50 ml of water q 8 hours. B. Check for tube placement and residual volume q4 hours. C. Obtain a daily x- ray to verify tube placement. D. Position on left side with head of bed elevated 45 degrees B - Percutaneous endoscopic gastrostomy (PEG) tube placement and residual volume should be checked every four hours for clients on continuous feeding. If the gastric residual is more than 200mL for an adult client; stop the feeding and re-check the gastric residual one hour later. If the residual still remains more than 200mL; continue to keep the feeding on hold and contact the client's health care provider. 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 - 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 help prevent further bone loss. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? A. Facial flushing. B. Fever. C. Pounding headache. D. Feelings of dizziness. D - Feelings of dizziness may occur as the result of a decreased heart rate, leading to a decreased cardiac output which may be an indication of pacemaker failure. 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. Prescription for removal of the drain. D. If the client's wound is infected. D - 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 for the nurse to verify the condition of the wound and if infected, important to place client in a private room. The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) A. Remove the diaphragm immediately after intercourse. B. Wash the diaphragm with an alcohol solution. C. Use the diaphragm to prevent conception during the menstrual cycle. D. Do not leave the diaphragm in place longer than 8 hours after intercourse. E. Replace the old diaphragm every 3 months. D, E - The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of toxic shock syndrome. The diaphragm should be replaced every 3 months to maintain integrity. A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client? A. Information about smoking cessation. B. Diet instructions for a low-residue diet. C. Instructions on a weight-loss program. D. The importance of increasing milk in the diet. A - Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management 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 - 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. A young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond? A. Propose sperm banking before RT then artificial insemination is an option. B. Suggest adoption when the client is in remission or ready for parenting. C. Tell the client that infertility is a non-reversible side effect of radiotherapy. D. Explain that sperm production will be suppressed after radiotherapy is over. A - Radiation at high doses kills the stem cells that produce sperm. While infertility after radiotherapy often occurs, the nurse should be supportive and offer alternatives that address the client's concerns and treatment decisions. Suggesting sperm banking is the most sensitive and supportive response The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? A. Exercise bicycle. B. Sphygmomanometer. C. Blood glucose monitor. D. Weekly medication box. B -Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record. The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? A. Two weeks before menstruation. B. Vaginal mucous discharge is thick. C. Low basal temperature. D. First thing in the morning. A - Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle. Sexual intercourse should occur within 24 hours of ovulation for an increase chance of conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not as significant in determining conception as the day before and after ovulation Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.) A. Quality of the pain. B. Signs of inflammation. C. Ankle range of motion. D. Muscle strength testing. E. Visible deformities of the joint. A, B, C, E - Initial assessment of a joint injury is performed to determine the extent of the damage. The nurse's initial assessment of a painful ankle injury should include pain quality, the presence of deformities, evidence of inflammation, and range of motion.Jarvis Physical Examination and Health Assessment, 7th ed. p. 586-8 During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? A. Racing pulse with exertion. B. Clubbing of the fingers. C. An increased chest diameter. D. Productive cough with grayish-white sputum. D - Chronic bronchitis, one of the diseases comprising the diagnosis of chronic obstructive pulmonary disease (COPD), is characterized by a productive cough with grayish-white sputum. 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 - A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding occurs. The purpose is to have the tourniquet available to apply to the residual limb to control bleeding if hemorrhaging was to occur. The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Have you ever sustained a severe head injury?" C. "Have you ever been 'frozen' in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" C - Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to a spot and unable to move, referrerd to as being "frozen" in one spot. Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? A. Hoarseness. B. Dry mouth. C. Mouth ulcers. D. Weight loss A - Dyspepsia and regurgitation are the main symptoms of gastroesophageal reflux disease (GERD); however, hoarseness is one of the most common long-term symptoms of GERD due to the irritation of the reflux of gastric secretions An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues. A. Abdominal distention B. Undue fatigue. C. Cyanosis of the lips. D. Confusion and tachycardia D - The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch. Cyanosis is a very late sign. The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis? A. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L. B. pH 7.45 , pCO 2 37 mmHg, HCO 3 24 mEq/L. C. pH 7.34, pCO 2 36 mmHg, HCO 3 21 mEq/L. D. pH 7.46, pCO 2 35 mmHg, HCO 3 28 mEq/L A - Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO2 higher than normal, and HCO3 within normal limits. A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client? A. pulse rate, both apically and radially. B. blood pressure, both standing and sitting. C. temperature. D. skin color and turgor. C - Long term use of steroids by COPD clients is effective in suppressing inflammation in their airways making it easier for them to breath, but at the same time suppresses the immune system, placing the client at risk for infection, so it is very important to obtain the client's temperature. Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. Hematuria. B. 2 pounds weight gain. C. 3+ bacteria in urine. D. Steady, dull flank pain. C - Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD) require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease so bacteria in the urine would be significant finding. The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? A. Diabetes mellitus. B. Hypothyroidism. C. Parkinson's disease. D. Recurring pneumonia. A - According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilized by the cells, leading to increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would 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 - 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). After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes. A - After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? A. Assess neurovascular status. B. Change the client's position. C. Inspect the traction equipment. D. Review pain medication orders. A - The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority. The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis. D - The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration . When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching? A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medic alert card stating that he is a total neck breather. D. Tell the client not to travel alone. C- It is imperative that total neck breathers carry a medic alert notice so, that if they have a cardiac arrest, mouth-to-neck breathing can be done Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? A. Black. B. White. C. Light green. D. Medium yellow. D - The color yellow is the easiest for a person with failing vision to see A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? A. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. Gram-negative pneumonias usually affect infants and small children. B - Gram-negative organisms are very resistant to drug therapy which makes recovery difficult. Antibiotic resistance has become a world-wide concern and the World Health Organization is keeping a very close surveillance on these occurrences. 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 - A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test. 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 - A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema. The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which laboratory test result should the nurse expect an increase in the serum level? A. Sodium. B. Antidiuretic hormone. C. Potassium. D. Glucose. C - Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by primary aldosteronism. 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 - 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. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would 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 - A daily record in handwriting may provide evidence of progression of hepatic encephalopathy leading to coma. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be 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 - An older person's level of activity is a determining factor in adjustment to aging as described by the Activity Theory of Aging. The most useful information initially would be an assessment of each individual's adjustment to the aging process. Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? A. Numbness, tingling, and cramps in the extremities. B. Headache, diaphoresis, and palpitations. C. Cyanosis, fever, and classic signs of shock. D. Nausea, vomiting, and muscular weakness. B - Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla, and a headache, profuse sweating and palpitations is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal of the tumor is the only treatment. 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 - 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. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor. A - When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority 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 - 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 is another common finding associated with endometriosis. 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 -Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene. The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which 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 - Achieving a healthy weight is critical to protect the joints of clients with osteoarthritis (OA). Weight loss for obese clients will take off the excess pressure that weight bearing joints such as the hips and knees are exposed to and reduce the wear and tear of the joints. Which condition should the nurse suspect when a client reports vaginal dryness during intercourse? A. Obstructed Bartholin's glands. B. Hyperactive sebaceous glands. C. Infected bulbourethral glands. D. Strangulated prostate gland. A -Bartholin's glands are located posteriorly on each side of the vaginal opening; they secrete lubrication fluid during sexual excitement. The nurse should suspect obstructed Bartholin's glands when a client reports vaginal dryness during intercourse. A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes. C. Intermittent claudication. D. Peripheral cyanosis. A - Clients who suffer from chroninc venous insufficiency often develop statsis dermatitis in the lower extremities. Statis dermatitis appear as brownish-red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart 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 one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas) and/or a CD4+ T cell count less than 200 (normal count 1,000). A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to notify the healthcare provider for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside. C -Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention. Which description of pain is consistent with a diagnosis of rheumatoid arthritis? A. Joint pain is worse in the morning and involves symmetric joints. B. Joint pain is better in the morning and worsens throughout the day. C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints. A - Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? A. "Check it again in one month, and if it is still there schedule an appointment." B. "Most lumps are benign, but it is always best to come in for an examination." C. "Try not to worry too much about it, because usually, most lumps are benign." D. "If you are in your menstrual period it is not a good time to check for lumps." B - The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. 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 - The use of an intrauterine device (IUD) provides the client with no protection from sexually transmitted diseases (STD). A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea. Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever. 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 - The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease. A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? A. Release the traction q4h to provide skin care. B. Turn the client for back care while suspending traction. C. Provide back and skin care while maintaining the traction. D. Give back care after the client is released from traction. C -Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed and is the correct intervention to maintain the client's skin integrity. 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 - 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. Risk factors which increase the condition of sleep apnea include: excessive weight, increases the risk 4 times more than normal weighing individuals; neck circumference, thicker necks have narrower airways; individuals with inherited narrower airways; males in general are more prone to sleep apnea; females risk increase with being overweight and post-menopausal; increased age (geriatrics); family history; use of alcohol, sedatives or tranquilizers; smokers and those who suffer from nasal allergies. A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis. C - Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? A. Horizontal white banding. B. Diffuse blue discoloration. C. Diffuse brown discoloration. D. Thin, dark red vertical lines. A - Fingernails and toenails can be affected by chronic kidney disease. This condition may cause horizontal white lines or bands (leukonychia) to appear on the nails.Ignatavicius,(2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 24, p. 426. A female client receiving IV vasopressin 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? A. Start an IV nitroglycerin infusion. B. Nasogastric lavage with cool saline. C. Increase the vasopressin infusion. D. Prepare for endotracheal intubation. A - Vasopressin is used to promote vasoconstriction, thereby reducing bleeding from the esophageal varice. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol. The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment? 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 - Hypokalemia 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). An older adult 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. Which 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 - Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed before notifying social services or discussing a need for counseling. An older adult 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 would 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 - Thrombophlebitis pain is relieved by rest and elevation of the extremity. 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. 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 - Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances. A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) A. Marijuana cigarettes do not affect sperm count. B. Alcohol consumption can cause erectile dysfunction. C. Low testosterone levels affect sperm production. D. Cessation of smoking improves general health and fertility. E. Obesity has no effect on sperm production. B, C, D -Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity. Which statement made by a client with chronic pancreatitis indicates that further education is needed? A. I will cut back on smoking cigarettes daily. B. I will avoid drinking caffeinated beverages. C. I will rest frequently and avoid vigorous exercise. D. I will eat a bland, low-fat, high-protein diet. A -To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein. 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 breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender. The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? A. Two weeks before menstruation. B. Vaginal mucous discharge is thick. C. Low basal temperature. D. First thing in the morning. A - Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle. Sexual intercourse should occur within 24 hours of ovulation for an increase chance of conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not as significant in determining conception as the day before and after ovulation 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 - 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 placing a book or magazine, helps the client visualize the rise and fall of the abdomen. 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 -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 into the cell for energy, so the outcome statement should include stabilization of adequate cellular nutrition which is done by providing the insulin supplement the client needs. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide? A. Estrogen deficiency causes the vaginal tissues to become dry and thinner. B. Infrequent intercourse results in the vaginal tissues losing their elasticity. C. Dehydration from inadequate fluid intake causes vulva tissue dryness. D. Lack of adequate stimulation is the most common reason for dyspareunia. A - Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier, and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. The discomfort during intercourse, primary cause can be contributed to the decrease in estrogen hormone levels. A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Jewish European ancestry. B. H. pylori bowel infection. C. Family history of irritable bowel syndrome. D. Age between 25 and 55 years. A - Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry. 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 - Buerger's disease is strongly related to smoking or the use of some other form of tobacco which affects the circulation in the arms and legs leading to infection and gangrene and sometimes amputation of the affected area. The most effective means of controlling symptoms and disease progression is through smoking cessation. The cause of Buerger's disease is unknown; a genetic predisposition is possible, but unproven. 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. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A. This is a normal auscultatory finding. B. May indicate pneumothorax. C. May indicate pneumonia. D. May indicate severe emphysema. C - This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding. A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client? A. "What dose of medication are you taking?" B. "Are you eating foods rich in potassium?" C. "Have you lost weight recently?" D. "At what time do you take your medication?" D - For a client taking a loop diuretic who complains of sleep issues, the nurse needs to first determine at what time of day the client takes the medication. Because of the diuretic effect of furosemide, clients should take the medication in the morning to prevent nocturia which may be the reason for the sleep difficulties. 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 - To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels. A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit? A. Elevated LDH. B. Elevated serum amylase. C. Elevated CK-MB. D. Elevated hematocrit. C - The cardiac isoenzyme CK-MB (C) is the one of the cardiac markers to indicate myocardial damage in the presence of MI symptoms and after a positive troponin. The troponin levels will elevate within 2-3 hours indicating myocardial ischemia, followed by the CK-MB cardiac markers within 6-9 hours, peaking within 12 to 20 hours after myocardial infarction (MI).