- A client is hospitalized with acute pancreatitis. The nursing assistant reports to the nurse
that when a blood pressure cuff was applied, the client’s hand had a spasm. Which additional
finding does the nurse correlate with this condition?
a. Serum calcium, 5.8 mg/dL
b. Serum sodium, 166 mEq/L
c. Serum creatinine, 0.9 mg/dL
d. Serum potassium, 4.2 mEq/dL
ANS: A
Spasm of the hand when a blood pressure cuff is applied (Trousseau’s sign) is indicative of
hypocalcemia. The client’s calcium level is low. The sodium level is high, but that is not related
to Trousseau’s sign. Creatinine and potassium levels are normal. - The nurse is caring for a client with cholecystitis. The client is a poor historian and is
unable to tell the nurse when the symptoms started. Which assessment finding indicates to the
nurse that the condition is chronic rather than acute?
a. Temperature of 100.1° F (37.8° C)
b. Positive Murphy’s sign
c. Light-colored stools
d. Upper abdominal pain after eating
ANS: C
Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic than with
acute cholecystitis. The other symptoms are seen equally with both conditions. - 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? (Select all that apply.)
a. “Take a 20-minute walk at least 5 days each week.”
b. “Attend local Alcoholics Anonymous (AA) meetings weekly.”
c. “Choose whole grains rather than foods with simple sugars.”
d. “Use cooking spray when you cook rather than margarine or butter.”
e. “Stay away from milk and dairy products that contain lactose.”
f. “We can talk to your doctor about a prescription for nicotine patches.”
ANS: B, D, F
The client should be advised to stay sober, and AA is a great resource. The client requires a lowfat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes,
he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help
the client quit smoking. The client must rest until his or her strength returns. The client requires
high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple
ones. Dairy products do not cause a problem. - A client has received vasopressin (DDAVP) for diabetes insipidus. Which assessment
finding indicates a therapeutic response to this therapy?
a. Urine output is increased; specific gravity is increased.
b. Urine output is increased; specific gravity is decreased.
c. Urine output is decreased; specific gravity is increased.
d. Urine output is decreased; specific gravity is decreased.
ANS: C
Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as
evidenced by a low specific gravity. Effective treatment results in decreased urine output that is
more concentrated, as evidenced by an increased specific gravity. - A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before
surgery. Which precautions does the nurse teach this client?
a. “Read the label before using salt substitutes.”
b. “Do not add salt to your food when you eat.”
c. “Avoid exposure to sunlight.”
d. “Take Tylenol instead of aspirin for pain.”
ANS: A
Spironolactone is a potassium-sparing diuretic used to control potassium levels. Its use can lead
to hyperkalemia. Although the goal is to increase the client’s potassium, unknowingly adding
potassium can cause complications. Some salt substitutes are composed of potassium chloride
and should be avoided by clients on spironolactone therapy. Depending on the client, he or she
may benefit from a low-sodium diet before surgery, but this may not be necessary. Avoiding
sunlight and Tylenol is not necessary. - Which serum laboratory values alert the nurse to the possibility of hyperaldosteronism?
(Select all that apply.)
a. Sodium, 150 mEq/L
b. Sodium, 130 mEq/L
c. Potassium, 2.5 mEq/L
d. Potassium, 5.0 mEq/L
e. pH, 7.28
f. pH, 7.50
ANS: A, C, E
Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism
causes hypernatremia, hypokalemia, and metabolic alkalosis. The other values are not indicative
of hyperaldosteronism. - Which dietary modification does the nurse provide for a client with hyperthyroidism?
a. Decreased calories and proteins and increased carbohydrates
b. Elimination of carbohydrates and increased proteins and fats
c. Increased calories, proteins, and carbohydrates
d. Supplemental vitamins and reduction of calories
ANS: C
The client is hypermetabolic and has an increased need for calories, carbohydrates, and proteins.
Proteins are especially important because the client is at risk for a negative nitrogen balance. The
other modifications are inappropriate for a client with hyperthyroidism. - A client with hyperthyroidism is taking lithium carbonate. Which finding indicates that the
client is having side effects of this therapy?
a. Blurred vision
b. Increased thirst and urination
c. Increased sweating and diarrhea
d. Decreased attention span and insomnia
ANS: B
Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. The
other choices are not specific to lithium. - Which client statement alerts the nurse to the possibility of hypothyroidism?
a. “My sister has thyroid problems.”
b. “I seem to feel the heat more than other people.”
c. “Food just doesn’t taste good without a lot of salt.”
d. “I am always tired, even with 10 or 12 hours of sleep.”
ANS: D
Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep.
Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of
taste is not a manifestation of hyperthyroidism. - A client has been diagnosed with hypothyroidism. Which medication is the nurse prepared to
administer to treat the client’s bradycardia?
a. Atropine sulfate
b. Levothyroxine sodium (Synthroid)
c. Propranolol (Inderal)
d. Epinephrine (Adrenalin)
ANS: B
The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using
levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine
or epinephrine might be an option for short-term management. Inderal is a beta blocker and
would be contraindicated for a client with bradycardia. - A client has hypothyroidism. Which problem does the nurse address as a priority for this
client?
a. Heat intolerance
b. Body image problems
c. Depression and withdrawal
d. Obesity
ANS: C
Hypothyroidism causes many problems in psychosocial functioning. Depression is the most
common reason for seeking medical attention. Memory and attention span may be impaired. The
client’s family may have great difficulty accepting and dealing with these changes. The client is
often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to
ensure that the client’s environment is safe. Heat intolerance is seen in hyperthyroidism. Body
image problems and weight issues do not take priority over mental status and safety. - A client has hypothyroidism and has been started on levothyroxine (Synthroid). Which
assessment finding leads the nurse to conclude that the treatment is effective?
a. Thirst is recognized and the client drinks fluids appropriately.
b. Weight has been the same for 3 weeks.
c. Total white blood cell count is 6000 cells/mm3
.
d. Heart rate is 70 beats/min and regular.
ANS: D
Hypothyroidism decreases body functioning and can result in effects such as bradycardia,
confusion, and constipation. If a client’ s heart rate is bradycardic while on thyroid hormone
replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart
rate above 100 beats/min may indicate that the client is receiving too much of the thyroid
hormone. The other assessment findings do not give any indication as to whether treatment is
successful. - A client with hypothyroidism as a result of Hashimoto’s thyroiditis asks the nurse how long
she will have to take thyroid medication. Which is the nurse’s best response?
a. “You will need to take the thyroid medication until the goiter is completely gone.”
b. “Thyroiditis is cured with antibiotics. Then you won’t need thyroid medication.”
c. “You’ll need thyroid pills for life because your thyroid won’t start working again.”
d. “When blood tests indicate normal thyroid function, you can stop the medication.”
ANS: C
Hashimoto’s thyroiditis results in a permanent loss of thyroid function. The client will need
lifelong thyroid replacement therapy. The other answers are incorrect. - A client being treated for hypothyroidism has been admitted for pneumonia. Which activity
does the nurse include as a priority in this client’s care plan?
a. Monitor the client’s IV site every shift.
b. Administer acetaminophen (Tylenol) for fever.
c. Ensure that working suction equipment is in the room.
d. Assess vital signs every 4 hours.
ANS: C
A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this
emergency situation, maintaining an airway is a priority. The nurse should ensure that suction is
available in the client’s room because it may be needed if myxedema coma develops. The other
interventions are necessary for any client with pneumonia, but having suction available is a
safety feature for this client. - A client with diabetes has a serum creatinine of 1.9 mg/dL. The nurse correlates which
urinalysis finding with this client?
a. Ketone bodies in the urine during acidosis
b. Glucose in the urine during hyperglycemia
c. Protein in the urine during a random urinalysis
d. White blood cells in the urine during a random urinalysis
ANS: C
Urine should not contain protein. The presence of proteinuria in a diabetic client marks the
beginning of kidney problems known as diabetic nephropathy, which progresses eventually to
end-stage kidney disease. Decline in kidney function is assessed with serum creatinine. This
client’s creatinine level is high. The other findings would not be correlated with declining kidney
function. - A client has newly diagnosed diabetes. To delay theonset of microvascular and macrovascular
complications in this client, the nurse stresses that the client take which action?
a. Control hyperglycemia.
b. Prevent hypoglycemia.
c. Restrict fluid intake.
d. Prevent ketosis.
ANS: A
Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.
Maintaining tight glycemic control will help delay the onset of complications. Preventing
hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic
control. Restricting fluid intake is not part of the treatment plan for clients with diabetes. - A client with diabetes has proliferative retinopathy, nephropathy, and peripheral neuropathy.
Which statement by the client indicates a good understanding of the disease and exercise?
a. “Because I have so many complications, I guess exercise is not a good idea.”
b. “I have so many complications that I better exercise hard to keep from getting worse.”
c. “I love to walk outside, but I probably better avoid doing that now.”
d. “I should look into swimming or water aerobics to get my exercise.”
ANS: D
Exercise is not contraindicated for this client, although modifications based on existing
pathology are necessary to prevent further injury. Swimming or water aerobics will give the
client exercise without the worry of having the correct shoes or developing a foot injury. The
client can walk outside if this is the exercise that he or she prefers. The client should not exercise
too vigorously. - A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the
nurse takes priority?
a. Administration of oxygen by mask or nasal cannula
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin
ANS: D
The rapid, deep respiratory efforts of Kussmaul respiration is the body’s attempt to reduce the
acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and
who does not also have a respiratory impairment does not need additional oxygen. Only the
administration of insulin will reduce this type of respiration by assisting glucose to move into
cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated.
The client does not require Seizure Precautions. - The home care nurse visits an older client with diabetes. For which nutritional problem does
the nurse monitor this client?
a. Obesity
b. Malnutrition
c. Alcoholism
d. Hyperglycemia
ANS: B
Older adults are more at risk for developing malnutrition as a result of multiple factors.
Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and
lack of understanding about which foods constitute an adequate diet all contribute to an increased
risk for malnutrition in all older adult clients, including those with diabetes mellitus - A client is receiving IV insulin for hyperglycemia. Which laboratory value requires
immediate intervention by the nurse?
a. Serum chloride level of 98 mmol/L
b. Serum calcium level of 8.8 mg/dL
c. Serum sodium level of 132 mmol/L
d. Serum potassium level of 2.5 mmol/L
ANS: D
Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium
from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In
hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride
level is normal. The calcium and sodium levels are slightly low, but this would not be related to
hyperglycemia and insulin administration. - The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching
point by the nurse is most accurate?
a. Ketosis is less prevalent among obese adults owing to the protective effects of fat.
b. People with type 2 diabetes have normal lipid metabolism, so ketones are not made.
c. Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia.
d. Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).
ANS: C
Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy
production. The client with type 1 diabetes becomes ketotic because he or she produces no
insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production
continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose
levels in the normal range but permits just enough glucose to enter cells for energy production,
so that fats are not catabolized for this purpose. The other rationales are incorrect. - A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the
nurse monitor the client most closely for?
a. Shallow slow respirations and respiratory alkalosis
b. Decreased urine output and hyperkalemia
c. Tachycardia and orthostatic hypotension
d. Peripheral edema and dependent pulmonary crackles
ANS: C
DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension.
Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output
(polyuria) is s evere. Because of diuresis and dehydration, peripheral edema and crackles do not
occur. - The nurse is caring for a critically ill client who has diabetic ketoacidosis (DKA). The nurse
finds the following assessment data: blood pressure, 90/62; pulse, 120 beats/min; respirations, 28
breaths/min; urine output, 20 mL/1 hour per catheter; serum potassium, 2.6 mEq/L. The health
care provider orders a 40 mEq potassium bolus and an increase in the IV flow rate. Which action
by the nurse is most appropriate?
a. Give the potassium after increasing the IV flow rate.
b. Increase the IV rate; consult the provider about the potassium.
c. Increase the IV rate; hold the potassium for now.
d. Infuse the potassium first before increasing the IV flow rate.
ANS: B
The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV
fluids and potassium. However, potassium should not be infused unless the urine output is at
least 30 mL/hr. The nurse should first increase the IV rate, then consult with the provider about
the potassium. The nurse should not just hold the potassium without consulting the provider
because the client’s level is dangerously low. - Which client is at greatest risk for development of a bacterial cystitis?
a. Older woman not taking estrogen replacement
b. Older man with mild congestive heart failure
c. Middle-aged woman who has never been pregnant
d. Middle-aged man taking cyclophosphamide for cancer therapy
ANS: A - A client with severe bacterial cystitis is prescribed cefadroxil (Duricef) and phenazopyridine
(Pyridium). What statement by the client indicates an accurate understanding of these
medications?
a. “I will not take these drugs with food or milk.”
b. “I will stop these drugs if I think I am pregnant.”
c. “An orange color in my urine won’t alarm me.”
d. “I will try to drink a liter of cranberry juice daily.”
ANS: C - Which statement made by a client with stress incontinence indicates a need for clarification of
nutrition therapy?
a. “I will limit my total intake of fluids.”
b. “I will avoid drinking alcoholic beverages.”
c. “I will avoid drinking caffeinated beverages.”
d. “I will try to lose about 10% of my body weight.”
ANS: A - The nurse is working in an incontinence clinic and sees older clients. The nurse plans a habit
training program for the client with which condition?
a. Confusion
b. Diabetes
c. Early kidney failure
d. Arthritis
ANS: A - The nurse is working in a long-term care facility where many clients use habit training to
manage incontinence. Which action by unlicensed assistive personnel (UAP) requires
intervention by the nurse?
a. Toileting clients after meals
b. Changing incontinence briefs when wet
c. Encouraging clients to drink fluids
d. Recording incontinence episodes
ANS: B - A client has overflow incontinence. Which intervention does the nurse add to this client’s
care plan to assist with elimination?
a. Stroking the medial aspect of the thigh
b. Using intermittent catheterization
c. Providing digital anal stimulation
d. Using the Valsalva maneuver
ANS: D - A client has a history of renal calculi. Which statement by the client indicates a good
understanding of preventive measures?
a. “I know I should drink at least 3 to 4 liters of fluid every day.”
b. “I can’t eat much dairy or other sources of calcium.”
c. “Aspirin and aspirin-containing products can lead to stones.”
d. “The doctor will give me antibiotics at the first sign of a stone.”
ANS: A - Which type of incontinence is most common after a difficult vaginal delivery?
a. Stress
b. Urge
c. Reflex
d. Overflow
ANS: A - A client has functional urinary incontinence. Which instruction by the nurse to the client and
family helps meet an expected outcome for this condition?
a. “You must clean around your catheter daily with soap and water.”
b. “Wash the vaginal weights with a 10% bleach solution after each use.”
c. “Operations to repair your bladder are available, and you can consider these.”
d. “Buy slacks with elastic waistbands that are easy to pull down.”
ANS: D - A client in the emergency department reports extreme dry mouth,constipation, and an
inability to void. The client’s history includes incontinence. Which question by the nurse is most
important?
a. “Are you drinking plenty of water?”
b. “Do you take anticholinergic medication?”
c. “Have you tried laxatives or enemas?”
d. “Has this type of thing ever happened before?”
ANS: B - A client has had two episodes of bacterial cystitis in the last 6 months. Which questions should
the nurse ask? (Select all that apply.)
a. “How much water do you drink every day?”
b. “Do you take estrogen replacement?”
c. “Does anyone in your family have a history of cystitis?”
d. “Do you have any condition that affects your immune system?”
e. “Are you on steroids or other immune suppressant drugs?”
f. “Do you drink grapefruit juice every day?”
ANS: A, B, D, E - Which statements about urge incontinence and stress incontinence are true? (Select all that
apply.)
a. Urge incontinence involves a post-voiding residual volume less than 50 mL.
b. Stress incontinence occurs because of weak pelvic floor muscles.
c. Stress incontinence usually occurs in people with dementia.
d. Urge incontinence can be managed by increasing fluid intake.
e. Urge incontinence occurs because of abnormal bladder contractions.
ANS: B, E - On assessment of a client with polycystic kidney disease (PKD), which finding is of greatest
concern to the nurse?
a. Flank pain
b. Periorbital edema
c. Bloody and cloudy urine
d. Enlarged abdomen
ANS: B - A client with autosomal dominant polycystic kidney disease (ADPKD) asks whether his
children could develop this disease. Which is the nurse’s best response?
a. “No genetic link is known, so your children are not at increased risk.”
b. “The disease is sex linked, so only your sons could be affected.”
c. “Both you and your wife must have the disease for your children to develop it.”
d. “Each of your children has a 50% risk of having ADPKD.”
ANS: D - A client with polycystic kidney disease and hypertension is prescribed a diuretic for blood
pressure control. Which statement by the client indicates the need for further teaching regarding
these orders?
a. “I will weigh myself every day at the same time.”
b. “I will drink only 1 liter of fluid each day.”
c. “I will avoid aspirin and aspirin-containing drugs.”
d. “I will avoid nonsteroidal anti-inflammatory drugs.”
ANS: B - A client with polycystic kidney disease (PKD) has received extensive teaching in the clinic.
Which statement by the client indicates that an important goal related to nutrition is being met?
a. “I take a laxative every night before going to bed.”
b. “I have a soft bowel movement every morning.”
c. “Food tastes so much better since I can use salt again.”
d. “The white bread I am eating does not cause gas.”
ANS: B - A client has a large renal calculus. Which assessment finding may indicate the development of a
complication?
a. Blood pressure of 178/94 mmHg
b. Urine output of 5600 mL/24 hr
c. Client reports of pain on urination
d. Asymmetric, tender flank area
ANS: D - In assessing a client recently diagnosed with acute glomerulonephritis, the nurse asks which
question to determine potential contributing factors?
a. “Are you sexually active?”
b. “Do you have pain or burning on urination?”
c. “Has anyone in your family had chronic kidney problems?”
d. “Have you had a cold or sore throat within the last 2 weeks?”
ANS: D - The nurse completes which ass
essment in a client with acute glomerulonephritis and periorbital edema?
a. Auscultating breath sounds
b. Checking blood glucose levels
c. Measuring deep tendon reflexes
d. Testing urine for protein
ANS: A - A client with glomerulonephritis has a glomerular filtration rate (GFR) of 40 mL/min, as
measured by a 24-hour creatinine clearance. Which is the nurse’s interpretation of this finding?
a. Excessive GFR, client at risk for dehydration
b. Excessive GFR, client at risk for fluid overload
c. Reduced GFR, client at risk for dehydration
d. Reduced GFR, client at risk for fluid overload
ANS: D - Which clinical manifestation indicates to the nurse that a client with glomerulonephritis (GN)
is responding as expected to the prescribed treatment?
a. The client has lost 11 pounds in the past 10 days.
b. The client’s urine specific gravity is 1.048.
c. No blood is observed in the client’s urine.
d. The client’s blood pressure is 152/88 mm Hg.
ANS: A - In interviewing a client with a family history of polycystic kidney disease (PKD), the nurse
assesses for which clinical manifestations most carefully? (Select all that apply.)
a. Nocturia
b. Flank pain
c. Diarrhea
d. Dysuria
e. Bloody urine
f. Increased abdominal girth
ANS: B, E, F - Which client is most at risk for developing postrenal kidney failure?
a. Client diagnosed with renal calculi
b. Client with congestive heart failure
c. Client taking NSAIDs for arthritis pain
d. Client recovering from glomerulonephritis
ANS: A
Causes of postrenal kidney failure include disorders that obstruct the flow of urine, such as renal
calculi. Heart failure can lead to prerenal failure, which is due to decreased blood flow to the
kidneys. Both NSAIDs and glomerulonephritis can damage the kidney, leading to intrarenal
failure. - The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an
LPN. Which information about the care of this client is most important for the RN to provide to the LPN?
a. “Avoid movement of the right extremity.”
b. “Place gentle pressure over the fistula site after blood draws.”
c. “Start any IV lines below the site of the fistula.”
d. “Take blood pressure in the left arm.”
ANS: D
Repeated compression of a fistula site can result in loss of vascular access. Therefore, avoid
taking blood pressures and performing venipunctures or IV placement in the arm with the
vascular access. The other statements are not appropriate. - The nurse is counseling a postmenopausal woman about her new stress incontinence. Which
statement by the nurse is most important?
a. “You can try a variety of briefs and undergarments.”
b. “It will be important to keep that area clean and dry.”
c. “I can refer you to a good incontinence clinic.”
d. “Unfortunately, incontinence is common in women your age.”
ANS: B
After menopause, the vagina becomes dry, thinner, and smoother. This atrophy places the vagina
at risk for infection. The combination of this fact with the presence of urine places the woman at
higher risk for infection. The nurse should teach the client good hygienic practices to reduce the
likelihood of infection. Education about briefs/undergarments may be needed, and a referral to an
incontinence clinic would be very helpful, but neither takes priority over preventing infection.
Stating that incontinence is common is not a helpful strategy. - An African-American client has a prostate-specific antigen (PSA) of 12 ng/mL. Which action
by the nurse is best?
a. Remind the client to repeat the test in 1 year.
b. Prepare the client for further diagnostic testing.
c. Ask if the client ejaculated within 48 hours of the test.
d. Assess the client for alcohol and tobacco use.
ANS: B
A normal PSA level is less than 4 ng/mL. Elevated PSA levels, particularly those over 10
ng/mL, are associated with cancer.African Americans tend to have higher PSA levels as they
age, but this level is so high that the nurse must suspect cancer and prepare the client for further
diagnostic testing. The client should not wait a year to repeat the test. The client should not
ejaculate for 24 hours before having blood drawn. Alcohol and tobacco use does not cause an
elevation in PSA. - A client recently had a mammogram. Which statement by the client indicates a need for
clarification regarding the importance or purpose of this procedure?
a. “Now that I have had a mammogram, my risk for getting breast cancer is reduced.”
b. “I will still do a breast self-examination monthly even after the mammogram.”
c. “Yearly mammograms can reduce my risk of dying from breast cancer.”
d. “The amount of radiation exposure from a mammogram is very low.”
ANS: A
Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists
in early detection and diagnosis and decreases the mortality rate from breast cancer. The client
should be instructed that the mammogram uses a very small amount of radiation in the test, and
that consistent scheduling of a mammogram, along with a breast self-examination performed at
least monthly, can reduce the client’s risk of dying from breast cancer. - A client who has discovered a lump in her breast becomes tearful when scheduling a
mammogram. Which is the nurse’s best response?
a. “All lumps are considered cancerous until proven otherwise.”
b. “Unless you have a relative with breast cancer, this lump is probably benign.”
c. “Diagnosing cancer at this early stage is most likely to result in a cure.”
d. “Many women have breast lumps, and most of the lumps are benign.”
ANS: D
The finding of a breast lump or mass is a frightening experience. Clients should be reassured,
until they can be seen or testing is done, that 90% of all breast lumps or masses are benign. It is
inaccurate for the nurse to state that all lumps are considered cancerous until proven benign, or
that the lump is probably benign unless the client has a relative with breast cancer. Diagnosing
cancer at an early stage results in cure more often than when the cancer is in later stages, but
such a comment before diagnosis will only scare the client more. - Which client does the nurse encourage to seek genetic counseling regarding her risk for
BRCA1 or BCRA2 gene mutation–related breast cancer?
a. Woman whose father had lung cancer and mother had leukemia
b. Woman whose sister has breast cancer and mother has ovarian cancer
c. Woman whose fraternal twin sister has breast cancer
d. Older woman who has bilateral benign breast disease
ANS: B
The best-defined increased genetic risk for breast cancer is related to mutations in the BRCA1 or
BRCA2 gene. Families in which either of these genes is mutated have higher rates of breast and
ovarian cancer in first-degree relatives. Being older is the primary risk factor for developing
breast cancer but is not related to the genetic component; neither is benign breast disease. Lung
cancer and leukemia are not genetically related to breast cancer. Having a twin with breast cancer
does increase the genetic risk, but not as much as having two first-degree relatives with related
cancers. - Which comment made by a client with breast cancer indicates correct understanding regarding
cancer causes and prevention?
a. “I will prevent recurrence of my cancer by eating a low-fat diet from now on.”
b. “If I had breast-fed my children, this would not have happened to me.”
c. “I hope this doesn’t increase my risk for bone cancer or lung cancer.”
d. “I will have regular mammograms on my other breast to detect cancer early.”
ANS: DRegular mammography can help detect breast cancer at an early stage. Women who have
had breast cancer have a greater risk of developing cancer in the other breast. The other
s tatements are inaccurate. - A client had a mastectomy nearly a year ago and is distressed over continued tingling and
burning in the ipsilateral arm. What orders does the nurse prepare to implement?
a. Teach the client about gabapentin (Neurontin).
b. Demonstrate the use of heat therapy to the axilla.
c. Discuss ways to prevent constipation with pain meds.
d. Reassure the client that this will disappear shortly.
ANS: A
Injury to nerves causes paresthesias such as burning, tingling, “pins and needles,” and numbness
after a mastectomy. These sensations are usually gone by the end of a year. Because this client’s
symptoms are distressing and have lasted so long, the nurse should anticipate an order for
Neurontin. Narcotic pain medications will not be helpful or needed. Heat therapy may or may
not be helpful, and reassuring the client at this point will sound unbelievable. - A client had a mastectomy and axillary node dissection. The nurse empties sanguineous
drainage from the client’s incisional Jackson-Pratt drain on the first postoperative day. Which
other action regarding the drain is of high priority for the nurse?
a. Flushing the tubing with urokinase to ensure patency
b. Compressing and closing the drain to ensure suction
c. Advancing the tubing inch from the insertion site
d. Clamping the drain for 2 hours and releasing it for 2 hours
ANS: B
The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be
compressed and closed to create suction as it slowly re-expands. The drain should never be
flushed with urokinase, tubing should not be advanced, and the drain should not be clamped and
released for 2 hours. - A client is postoperative from a left-sided mastectomy. She says that the incision and the
inner side of her arm from the armpit to the elbow are numb. Which is the nurse’s best action?
a. Teach the client to avoid lifting heavy objects.
b. Measure the circumference of the client’s left arm.
c. Reassure the client that this is an expected finding.
d. Notify the surgeon as soon as possible.
ANS: C
The nerves supplying the skin in the area were injured during surgery, decreasing sensation to the
area. These problems frequently resolve over time. Teaching the client to avoid lifting heavy
objects or measuring the circumference of the arm will not improve sensation to the client’s arm.
The surgeon does not need to be notified about normal findings. - A client asks how soon after a mastectomy she can engage in sexual activity. Which is the
nurse’s best response?
a. “When do you want to resume sexual activity?”
b. “Most surgeons say to wait several weeks after the operation.”
c. “As soon as the incision has healed completely.”
d. “You shouldn’t worry about sexuality right now.”
ANS: B
Most surgeons prefer that the client wait 4 to 6 weeks postoperatively before resuming sexual
activity, although this very personal advice should be individualized. Asking the client when she
wants to resume sexual activity places the burden on her to make a tentative decision. Until the
incision is healed, clients should be taught how to protect the incision and avoid contact with the
surgical site during intercourse. Telling the client not to worry about sexuality is dismissing and
disrespectful. - A client is experiencing lymphedema in the arm on the operative side after a modified radical
mastectomy. Which statement indicates correct understanding of managing this problem?
a. “I will reduce my intake of salt and water.”
b. “I will elevate my arm on a pillow at night.”
c. “I will try to drink at least 3 liters of water each day.”
d. “I will wear long sleeves to prevent sun exposure.”
ANS: B
The formation of edema is aggravated by having the arm in a position dependent to the heart.
Elevating the arm as much as possible assists gravity to promote better venous and lymph return.
This will be a more effective intervention than salt reduction or drinking large amounts of water.
Preventing sun exposure will have no effect on the lymphedema. - A client had a mastectomy with reconstruction, and several axillary nodes were dissected.
Which statement by the client indicates good understanding of discharge instructions?
a. “I must be careful not to injure the arm or hand on the side of my surgery.”
b. “I’m glad that lymphedema is no longer a problem, as it was in my mother’s day.”
c. “I will have a hard time waiting for a whole year to see how my breast will look.”
d. “I need to pull my drains out by inch each day until they are totally out.”
ANS: A
Lymphedema is a complication following mastectomy, especially if lymph nodes have been
removed. The client must use measures to prevent this from occurring for the rest of her life.
Preventing injury is one way of preventing lymphedema. Breast reconstruction should look
optimal in 3 to 6 months. The health care provider will remove drains at a postoperative
appointment. - The clinic nurse is preparing a client for a physical and breast examination. The nurse notes the
client’s breast appears as shown in the photograph below(dimpling of the skin). Which action by the
nurse takes priority?
a. Continue preparations and note the finding in the client’s chart.
b. Ask the client how long this problem has been present.
c. Alert the health care provider and prepare to order a mammogram.
d. Question the client about routine drug and alcohol intake.
ANS: C
This finding (dimpling of the skin) is suspicious for infiltrating ductal carcinoma. The nurse
should alert the provider and prepare to order a mammogram for the client. In addition, the nurse
should be prepared to refer the client to a breast specialist. The nurse does need to continue
preparing the client and document the finding, but this is not as important as the mammogram
and referral. Assessment can continue before, during, or after the examination, but is also not as
vital as facilitating further diagnostic testing. - A client is in the clinic reporting stress incontinence. Which other assessment is the priority for
the nurse to perform?
a. Ask the client about vaginal discharge or bleeding.
b. Have the client perform a 24-hour fluid recall.
c. Inquire about fever, chills, and burning on urination.
d. Obtain the client’s reproductive history.
ANS: A
Gynecologic problems are often accompanied by urinary symptoms. Because women are often
hesitant or embarrassed to discuss gynecologic problems, the nurse should specifically assess for
them in clients reporting urinary issues. The other assessments are important as well but are not
the priority. - A woman reports cyclical abdominal pain, and her pelvic examination reveals tender nodules
in the posterior vagina. The nurse plans to educate the woman about which treatment?
a. Medroxyprogesterone (Depo-Provera)
b. Radiation therapy
c. Doxycycline (Vibramycin)
d. Endometrial ablation
ANS: A
This client has manifestations of endometriosis, and menstrual cycle control is a common
therapy. Oral contraceptives or injectables such as Depo-Provera are often used. Radiation
therapy is used for cancer. Doxycycline is an antibiotic used for bacterial infection. Endometrial
ablation is a treatment used for dysfunctional uterine bleeding. - A woman has endometriosis and is visibly upset. She tells the nurse that she just got married
and wants to have children but is distressed because now she will be infertile. Which response by
the nurse is most appropriate?
a. “Treatment for endometriosis often causes infertility; I can refer you to a support group.”
b. “Endometriosis is more common in infertile women, but not all treatments cause infertility.”
c. “You shouldn’t worry about fertility until after we know that this didn’t cause cancer.”
d. “Unfo rtunately, you will have to take birth control pills for the rest of your life.”
ANS: B
Endometriosis is more common among infertile women than in the general population. However,
treatments can be chosen on the basis of symptoms, extent of the disease, and the woman’s desire
to remain fertile. Menstrual cycle control with hormones is often a choice and would not leave
the woman infertile. Endometriosis only rarely causes cancer. The woman would not have to take
birth control pills for the rest of her life.
Final Nursing Rev 3
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