Revise for final exam nursing

Which symptom experienced by a woman in her 20s alerts the nurse to the possibility of
endometriosis?
a. Bleeding between periods
b. Cessation of menstruation
c. Premenstrual tension headache
d. Pain before the onset of menstrual flow
ANS: D
Pain is the most common symptom of endometriosis. The peak of pain usually occurs just before
the menstrual flow.
Which action does the nurse teach the client to prevent toxic shock syndrome?
a. “Use a barrier method of contraception.”
b. “Wash your hands before inserting a tampon.”
c. “Avoid intercourse with more than one partner.”
d. “Empty your bladder immediately after intercourse.”
ANS: B
Certain strains of Staphylococcus aureus, commonly found on skin surfaces, produce a toxin that
can enter the bloodstream through the vaginal mucosa. Handwashing before tampon insertion
reduces the chance that the organism will enter the vagina.
A young woman calls the clinic to report a fever and a funny rash with peeling skin on the
palms of her hands and the soles of her feet. Which action by the nurse is most appropriate?
a. Make an appointment for her to be seen the next day at the clinic.
b. Instruct her to take warm baths with oatmeal added to the water.
c. Tell her to go to the emergency department immediately.
d. Have her take acetaminophen (Tylenol) every 4 hours and drink fluids.
ANS: C
These signs are consistent with toxic shock syndrome, a potentially life-threatening bacterial infection often
associated with tampon use in menstruating women. The client requires immediate medical attention and
should go to the nearest emergency department. Waiting until the next day, taking warm baths, and using
symptom control measures such as Tylenol and fluids only lead to delay in obtaining necessary care.
Which clinical manifestation in a client with invasive cervical cancer alerts the nurse to the
possibility of metastasis?
a. Amenorrhea
b. Weight gain
c. Breast tenderness
d. Swelling of one leg
ANS: D
Leg pain or unilateral swelling of a leg is a symptom of disease progression as the tumor
enlarges, or of recurrent disease.
A client has undergone cryosurgery for stage I cervical cancer. Which precaution or action
does the nurse teach this client?
a. “Use sanitary napkins to manage discharge for the next several weeks.”
b. “Avoid sexual intercourse or becoming pregnant for the next 12 months.”
c. “If you should become pregnant, you will be at increased risk for preterm labor.”
d. “Your next menstrual cycle will be delayed because of this procedure.”
ANS: A
The effects of cryosurgery include a heavy, watery vaginal discharge for 3 to 6 weeks after the
procedure. Clients are cautioned to avoid the use of tampons and intercourse during this time to
reduce the risk for infection. The other statements are inaccurate.
Why are the death rates from ovarian cancer so high?
a. The causative oncovirus is resistant to chemotherapy and to radiation.
b. No symptoms are obvious during the early stages of this disorder.
c. Radiation therapy is ineffective because the ovaries are located deep in the pelvis.
d. Ovarian cancer occurs mostly in women over the age of 70 who have other health
problems.
ANS: B
Ovarian cancer is poorly detected in its early stages, when the chances for cure or control are
better. The other statements are inaccurate.
Which statement indicates that a client understands the most appropriate time of day to take an
alpha blocker drug for treatment of benign prostatic hyperplasia (BPH)?
a. “I’ll take my medication at bedtime.”
b. “As soon as I get up, I will take my medication.”
c. “I will take my medication with food or milk.”
d. “I’ll take my medication on an empty stomach.”
ANS: A
Bedtime dosing should decrease the risk of hypotension with an alpha blocker drug. Giving the
medication during the day will increase the client’s risk of experiencing weakness,
lightheadedness, and dizziness.
A client’s prostate-specific antigen (PSA) level is 2.0 ng/mL. Which action by the nurse is
most appropriate?
a. Inform the client that the results are normal and no cancer has been detected.
b. Inform the client that results are normal and schedule a digital rectal examination.
c. Let the client know that the results are elevated and he is at risk for prostate cancer.
d. Tell the client that cancer is indicated and that the health care provider
recommends watchful waiting.
ANS: B
A normal PSA in men younger than age 50 is less than 2.5 ng/mL. Although the finding is within normal
limits for a PSA value, a client could have prostate cancer and not present with an elevated PSA. Also,
laboratory findings should not be used as the sole screening tool. Without a digital rectal examination
(DRE), the health care provider cannot know whether the client is in the early stages of prostate cancer. The
client should be informed that although the level is within the normal range, he still needs a DRE.
Which client diagnosed with prostate cancer is not a candidate for watchful waiting?
a. Client with very early cancer of the prostate
b. Client who is asymptomatic
c. Client who wants to avoid urinary incontinence as a result of treatment
d. Client who refuses frequent digital rectal examinations (DREs)
ANS: D
To participate in watchful waiting, the client must be monitored on a regular basis with a DRE
and prostate-specific antigen (PSA) testing. Clients who are asymptomatic, who have early
cancer, and who wish to avoid urinary incontinence from treatment would all be excellent
candidates for watchful waiting.
A client had a transurethral prostatectomy and has incontinence. Which statement by the
client indicates a need for clarification about managing this condition?
a. “I will practice stopping the urine stream to strengthen my sphincter control.”
b. “I will limit my fluid intake every day to prevent incontinence.”
c. “I will avoid vigorous activity for the first 3 weeks after surgery.”
d. “I will avoid caffeinated beverages and spicy foods.”
ANS: B
Unless fluid restriction is needed because of another medical problem, clients with incontinence
should drink plenty of water and other fluids. Client statements regarding Kegel exercises,
activity restrictions post-surgery, and avoiding bladder irritants are all indicative of
understanding.
The client with sickle cell anemia has had an erection for longer than 4 hours. How does the
nurse intervene?
a. Administer a diuretic to increase urine output.
b. Attempt to relieve pressure by catheterizing the client.
c. Document the finding and reassess in 4 hours.
d. Notify the health care provider and prepare to give meperidine (Demerol).
ANS: D
Prolonged penile erection—priapism—is common during sickle cell crisis. It is considered a
urologic emergency because circulation to the penis may be compromised, and the client may not
be able to void. Therefore, the provider must be notified promptly. Demerol is often given to
induce hypotension. A diuretic will not help the client. Catheterization should be reserved for the
man who cannot void. Waiting another 4 hours to intervene may lead to ischemia.
A client with BPH asks why his enlarged prostate is causing difficulty with urination. Which
is the nurse’s most accurate response?
a. “It compresses the urethra, blocking the flow of urine.”
b. “It presses on the kidneys, decreasing urine formation.”
c. “It secretes acids that weaken the bladder, causing dribbling.”
d. “It destroys nerves, decreasing awareness of a full bladder.”
ANS: A
The prostate gland encircles the urethra and bladder neck like a doughnut. Enlargement of the
gland constricts the urethra and obstructs the outflow of urine by encroaching on the bladder
ope ning. The other responses are inaccurate.
An older client with benign prostatic hyperplasia (BPH) and hypertension is being treated
with doxazosin (Cardura) while staying in the hospital. Which activity does the nurse delegate to
the unlicensed assistive personnel (UAP) as a priority?
a. Helping the client choose low-sodium meal items
b. Assisting the client whenever he gets out of bed
c. Encouraging the client to use the spirometer hourly
d. Frequently re-orienting the client to his surroundings
ANS: B
When treating a client in an inpatient setting with alpha blockers such as doxazosin (Cardura) or terazosin
(Hytrin), the nurse must provide for the client’s safety because this medication can cause orthostatic
hypotension or syncope. The nurse should instruct the UAP to help the client whenever he gets out of bed, to
prevent injury. Because this medication is being used for BPH and not for hypertension, a low-sodium diet is
not necessary. Using the spirometer is always a good intervention, but it use is not related to safety and to
this medication. The client, although older, may not be confused and may not need frequent reorientation.
A female client is diagnosed with human papilloma virus (HPV) infection. Which
intervention by the nurse takes priority?
a. Instruct the client on using podofilox (Condylox) cream.
b. Prepare the client for a Pap test and HPV DNA testing.
c. Teach the client to take all medications until they are gone.
d. Encourage the client to drink 8 to 10 glasses of water daily.
ANS: B
Because certain strains of HPV cause cervical cancer, the client needs to have a Pap smear and
HPV DNA testing done. The nurse should also teach her to use topical medications, such as
Condylox, but this is not as high a priority as diagnostic testing. The other two options are not
related to infection with HPV.
A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present
when she discloses this information to her adult daughter. How should the nurse respond?
a. “I will request a genetic counselor who is more qualified to be present for this conversation.”
b. “The test results can be confusing; I will help you interpret them for your daughter.”
c. “Are you sure you want to share this information with your daughter, who may not test positive for this
gene mutation?”
d. “This conversation may be difficult for both of you; I will be there to provide support.”
ANS: D
A nurse should provide emotional support while the client tells her daughter the information she
has learned about the test results. The nurse should not interpret the results or counsel the client
or her daughter. The nurse should refer the client for counseling or support, if necessary.
A nurse cares for a client who recently completed genetic testing that revealed that she has a
BRCA1 gene mutation. Which actions should the nurse take next? (Select all that apply.)
a. Discuss potential risks for other members of her family.
b. Assist the client to make a plan for prevention and risk reduction.
c. Disclose the information to the medical insurance company.
d. Recommend the client complete weekly breast self-examinations.
e. Assess the client’s response to the test results.
f. Encourage support by sharing the results with family members.
ANS: A, B, E
The medical-surgical nurse can assess the client’s response to the test results, discuss potential risks for other
family members, encourage genetic counseling, and assist the client to make a plan for prevention, risk
reduction, and early detection. For some positive genetic test results, such as having a BRCA1 gene mutation,
the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client should
have a plan for prevention and risk reduction. One form of prevention is early detection. Breast selfexaminations may be helpful when performed monthly, but those performed every week may not be useful,
especially around the time of menses. A client who tests positive for a BRCA1 mutation should have at least
yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured.
Owing to confidentiality, the nurse would never reveal any information about a client to an insurance
company or family members without the client’s permission.
A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a. Client with pancreatitis who has continuous nasogastric suctioning
b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d. Client with uncontrolled diabetes and a serum pH level of 7.33
ANS: A
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading
to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
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?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek’s sign
ANS: B The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic
acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and
Kussmaul respirations. Agitation, seizures, and a positive Chvostek’s sign are manifestations of the
electrolyte imbalances that accompany alkalosis.
A nurse cares for a client with colon cancer who has a new colostomy. The client states, “I think it
would be helpful to talk with someone who has had a similar experience.” How should the nurse respond?
a. “I have a good friend with a colostomy who would be willing to talk with you.”
b. “The enterostomal therapist will be able to answer all of your questions.”
c. “I will make a referral to the United Ostomy Associations of America.”
d. “You’ll find that most people with colostomies don’t want to talk about them.”
ANS: C
Nurses need to become familiar with community-based resources to better assist clients. The local chapter of
the United Ostomy Associations of America has resources for clients and their families, including Ostomates
(specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a
personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with
him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not
brush aside the client’s request by saying that most people with colostomies do not want to talk about them.
Many people are willing to share their ostomy experience in the hope of helping others.
A nurse cares for a client who states, “My husband is repulsed by my colostomy and refuses
to be intimate with me.” How should the nurse respond?
a. “Let’s talk to the ostomy nurse to help you and your husband work through this.”
b. “You could try to wear longer lingerie that will better hide the ostomy appliance.”
c. “You should empty the pouch first so it will be less noticeable for your husband.”
d. “If you are not careful, you can hurt the stoma if you engage in sexual activity.”
ANS: A
The nurse should collaborate with the ostomy nurse to help the client and her husband work
through intimacy issues. The nurse should not minimize the client’s concern about her husband
with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago.
The client states, “The stool in my pouch is still liquid.” How should the nurse respond?
a. “The stool will always be liquid with this type of colostomy.”
b. “Eating additional fiber will bulk up your stool and decrease diarrhea.”
c. “Your stool will become firmer over the next couple of weeks.”
d. “This is abnormal. I will contact your health care provider.”
ANS: A
The stool from an ascending colostomy can be expected to remain liquid because little large
bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid
stool from an ascending colostomy will not become firmer with the addition of fiber to the
client’s diet or with the passage of time.
A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which
assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)
a. Serum potassium of 2.8 mEq/L
b. Loss of 15 pounds without dieting
c. Abdominal pain in upper quadrants
d. Low-pitched bowel sounds
e. Serum sodium of 121 mEq/L
ANS: A, C, E
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is
hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145
mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction.
Dramatic weight loss without dieting followed by bowel obstruction leads to the probable
development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.
A nurse cares for a teenage girl with a new ileostomy. The client states, “I cannot go to prom
with an ostomy.” How should the nurse respond?
a. “Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance.”
b. “The pouch won’t be as noticeable if you avoid broccoli and carbonated drinks prior to the prom.”
c. “Let’s talk to the enterostomal therapist about options for ostomy supplies and dress styles.”
d. “You can remove the pouch from your ostomy appliance when you are at the prom so that it is less
noticeable.”
ANS: C
The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage
the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and
carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent,
so pouch removal during the prom is not feasible.
After teaching a client who is prescribed adalimumab(Humira) for severe ulcerative colitis, the nurse
assesses the client’s understanding. Which statement made by the client indicates a need for additional
teaching?
a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with my breakfast each morning.”
c. “Nausea and vomiting are common side effects of this drug.”
d. “I must wash my hands after I play with my dog.”
ANS: B
Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It
does not need to be given with food or milk. Nausea and vomiting are two common side effects.
Adalimumab can cause immune suppression, so clients receiving the medication should avoid
large crowds and people who are sick, and should practice good handwashing.
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The
client states, “I am having trouble swallowing this pill.” Which action should the nurse take?
a. Contact the clinical pharmacist and request the medication in suspension form.
b. Empty the contents of the capsule into applesauce or pudding for administration.
c. Ask the health care provider to prescribe the medication as an enema instead.
d. Crush the pill carefully and administer it in applesauce or pudding.
ANS: C
Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should
not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client
is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered
instead, with a provider’s order.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment
should the nurse complete first?
a. Inspection of oral mucosa
b. Recent dietary intake
c. Heart rate and rhythm
d. Percussion of abdomen
ANS: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the
client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from
severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte
replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal
percussion are important parts of physical assessment but are lower priority for this client than
heart rate and rhythm.
After teaching a client who has a new colostomy, the nurse provides feedback based on the client’s
ability to complete self-care activities. Which statement should the nurse include in this feedback?
a. “I realize that you had a tough time today, but it will get easier with practice.”
b. “You cleaned the stoma well. Now you need to practice putting on the appliance.”
c. “You seem to understand what I taught you today. What else can I help you with?”
d. “You seem uncomfortable. Do you want your daughter to care for your ostomy?”
ANS: B
The nurse should provide both approval and room for improvement in feedback after a teaching session.
Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will
improve does not offer anything concrete for the client to work on, nor does it let him or her know what
was done well. The nurse should not make the client convey learning needs because the client may not
know what else he or she needs to understand. The client needs to become the expert in self-management of
the ostomy, and the nurse should not offer to teach the daughter instead of the client.
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical
manifestation should alert the nurse to urgently contact the health care provider?
a. Pale and bluish stoma
b. Liquid stool
c. Ostomy pouch intact
d. Blood-smeared output
ANS: A
The nurse should assess the stoma for color and contact the health care provider if the stoma is
pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark
green liquid stool that may contain some blood.
A nurse cares for a client with a new ileostomy. The client states, “I don’t think my friends
will accept me with this ostomy.” How should the nurse respond?
a. “Your friends will be happy that you are alive.”
b. “Tell me more about your concerns.”
c. “A therapist can help you resolve your concerns.”
d. “With time you will accept your new body.”
ANS: B
Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should
encourage the client to discuss concerns. The nurse should not minimize the client’s concerns or
provide false reassurance.
A nurse cares for a client with ulcerative colitis. The client states, “I feel like I am tied to the
toilet. This disease is controlling my life.” How should the nurse respond?
a. “Let’s discuss potential factors that increase your symptoms.”
b. “If you take the prescribed medications, you will no longer have diarrhea.”
c. “To decrease distress, do not eat anything before you go out.”
d. “You must retake control of your life. I will consult a therapist to help.”
ANS: A
Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress
factors can increase symptoms. These factors should be identified so that the client will have
more control over his or her condition. Prescription medications and an orexia will not eliminate
exacerbations. Although a therapist may assist the client, this is not an appropriate response.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with
their physiologic processes? (Select all that apply.)
a. Lower gastrointestinal bleeding – Erosion of the bowel wall
b. Abscess formation – Localized pockets of infection develop in the ulcerated bowel lining
c. Toxic megacolon – Transmural inflammation resulting in pyuria and fecaluria
d. Nonmechanical bowel obstruction – Paralysis of colon resulting from colorectal cancer
e. Fistula – Dilation and colonic ileus caused by paralysis of the colon
ANS: A, B, D
Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of
infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is
paralysis of the colon that results from colorectal cancer. When the inflammation is transmural,
fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of
the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the
nurse assesses the client’s understanding. Which statement made by the client indicates a correct
understanding of the teaching?
a. “Drinking at least 2 liters of water each day is suggested.”
b. “I will decrease the amount of fatty foods in my diet.”
c. “Drinking fluids with my meals will increase bloating.”
d. “I will avoid concentrated sweets and simple carbohydrates.”
ANS: B
After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a
special diet is not recommended for most clients. Good fluid intake is healthy for all people but
is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which
is not seen with this procedure. Restriction of sweets is not required.
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The
client reports pain in the shoulder blades. How should the nurse respond?
a. “Ambulating in the hallway twice a day will help.”
b. “I will apply a cold compress to the painful area on your back.”
c. “Drinking a warm beverage can relieve this referred pain.”
d. “You should cough and deep breathe every hour.”
ANS: A
The client who has undergone a laparoscopic cholecystectomy may report free air pain due to
retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to
promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage
would not be helpful. Coughing and deep breathing are important postoperative activities, but
they are not related to discomfort from carbon dioxide.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse
include in this client’s plan of care to reduce discomfort?
a. Administer morphine sulfate intravenously every 4 hours as needed.
b. Maintain nothing by mouth (NPO) and administer intravenous fluids.
c. Provide small, frequent feedings with no concentrated sweets.
d. Place the client in semi-Fowler’s position with the head of bed elevated.
ANS: B
The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production.
IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain
medications should be given around the clock and more frequently than every 4 to 6 hours. A
fetal position with legs drawn up to the chest will promote comfort.
A nurse assesses clients at a community health center. Which client is at highest risk for
pancreatic cancer?
a. A 32-year-old with hypothyroidism
b. A 44-year-old with cholelithiasis
c. A 50-year-old who has the BRCA2 gene mutation
d. A 68-year-old who is of African-American ethnicity
ANS: C
Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in
a small number of cases. The other factors do not appear to be linked to increased risk.
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates 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 cholecystitis.
The other symptoms are seen equally with both chronic and acute cholecystitis.
A nurse cares for a client with acute pancreatitis. The client states, “I am hungry.” How
should the nurse reply?
a. “Is your stomach rumbling or do you have bowel sounds?”
b. “I need to check your gag reflex before you can eat.”
c. “Have you passed any flatus or moved your bowels?”
d. “You will not be able to eat until the pain subsides.”
ANS: C
Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this
has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead,
the nurse should assess for passage of flatus or bowel movement.
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the
nurse ask to ensure safety upon discharge?
a. “Do you have a one- or two-story home?”
b. “Can you check your own pulse rate?”
c. “Do you have any alcohol in your home?”
d. “Can you prepare your own meals?”
ANS: A
A client recovering from chronic pancreatitis should be limited to one floor until strength and
activity increase. The client will need a bathroom on the same floor for frequent defecation.
Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the
client should be encouraged to stop drinking alcoholic beverages, asking about alcohol
availability is not adequate to assess this client’s safety.
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should
the nurse include in this client’s teaching? (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 low-fat 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 nurse plans care for a client who has acute pancreatitis and is prescribed nothing by
mouth (NPO). With which health care team members should the nurse collaborate to provide
appropriate nutrition to this client? (Select all that apply.)
a. Registered dietitian
b. Nursing assistant
c. Clinical pharmacist
d. Certified herbalist
e. Health care provider
ANS: A, C, E
Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or
parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and
health care provider to plan and implement the more appropriate nutritional interventions. The nursing
assistant and cert ified herbalist would not assist with this clinical decision.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is
in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should
the nurse include when delegating care for this client? (Select all that apply.)
a. “Do not allow the client to eat between meals.”
b. “Make sure the client receives a protein shake.”
c. “Do not allow caffeine-containing beverages.”
d. “Make sure the foods are bland with little spice.”
e. “Do not allow high-carbohydrate food items.”
ANS: B, C, D
During the healing phase of pancreatitis, the client should be provided small, frequent, moderateto high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement
the diet. Foods and beverages should not contain caffeine and should be bland.
A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus.
Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.)
a. Urine output is increased.
b. Urine output is decreased.
c. Specific gravity is increased.
d. Specific gravity is decreased.
e. Urine osmolality is increased.
f. Urine osmolality is decreased.
ANS: A, D, F
Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolality, 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 nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which
assessment finding should alert the nurse to a side effect of this therapy?
a. Blurred and double vision
b. Increased thirst and urination
c. Profuse nausea and diarrhea
d. Decreased attention and insomnia
ANS: B
Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. This
manifests with increased thirst and urination. Lithium has no effect on vision, gastric upset, or
level of consciousness.
A nurse assesses a client on the medical-surgical unit. Which statement made by the client
should alert 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 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 hypothyroidism.
A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which
medication should the nurse anticipate being prescribed to the client?
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. Propranolol is a beta blocker and
would be contraindicated for a client with bradycardia.
A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse
plan to address first for this client?
a. Heat intolerance
b. Body image problems
c. Depression and withdrawal
d. Obesity and water retention
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 nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism.
Which assessment finding should alert the nurse that the medication therapy is effective?
a. Thirst is recognized and fluid intake is appropriate.
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. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic
response to this medication.
A nurse cares for a client who has hypothyroidism as a result of Hashimoto’s thyroiditis. The client
asks, “How long will I need to take this thyroid medication?” How should the nurse respond?
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 client will not be able to stop taking the medication.
A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia.
Which priority intervention should the nurse include in this client’s plan of care?
a. Monitor the client’s intravenous site every shift.
b. Administer acetaminophen (Tylenol) for fever.
c. Ensure that working suction equipment is in the room.
d. Assess the client’s 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 equipment 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 nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse
include in this client’s teaching? (Select all that apply.)
a. Increased carbohydrates
b. Decreased fats
c. Increased calorie intake
d. Supplemental vitamins
e. Increased proteins
ANS: A, C, E
The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins.
Proteins are especially important because the client is at risk for a negative nitrogen balance.
There is no need to decrease fat intake or take supplemental vitamins.
A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The
nurse notes that the client’s level of consciousness has decreased. Which actions should the nurse
take? (Select all that apply.)
a. Infuse intravenous fluids.
b. Cover the client with warm blankets.
c. Monitor blood pressure every 4 hours.
d. Maintain a patent airway.
e. Administer oral glucose as prescribed.
ANS: A, B, D
A client with hypothyroidism and an acute illness is at risk for myxedema coma. A decrease in
level of consciousness is a symptom of myxedema. The nurse should infuse IV fluids, cover the
client with warm blankets, monito r blood pressure every hour, maintain a patent airway, and
administer glucose intravenously as prescribed.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul
respirations. Which action should the nurse take?
a. Administration of oxygen via face mask
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 respirations are the body’s attempt to reduce the
acids produced by using fat rather than glucose for fuel. 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. The client who is in ketoacidosis may not experience any respiratory impairment
and therefore does not need additional oxygen. Giving the client glucose would be
contraindicated. The client does not require seizure precautions.
A nurse reviews the medication list of a client recovering from a computed tomography (CT)
scan with IV contrast to rule out small bowel obstruction. Which medication should alert the
nurse to contact the provider and withhold the prescribed dose?
a. Pioglitazone (Actos)
b. Glimepiride (Amaryl)
c. Glipizide (Glucotrol)
d. Metformin (Glucophage)
ANS: D
Glucophage should not be administered when the kidneys are attempting to excrete IV contrast
from the body. This combination would place the client at high risk for kidney failure. The nurse
should hold the metformin dose and contact the provider. The other medications are safe to
administer after receiving IV contrast.
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which
manifestations should the nurse monitor the client? (Select all that apply.)
a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension
ANS: A, C, E
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 severe. Because of diuresis and dehydration, peripheral edema and crackles do not
occur.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the
development of bacterial cystitis?
a. A 36-year-old female who has never been pregnant
b. A 42-year-old male who is prescribed cyclophosphamide
c. A 58-year-old female who is not taking estrogen replacement
d. A 77-year-old male with mild congestive heart failure
ANS: C
Females at any age are more susceptible to cystitis than men because of the shorter urethra in
women. Postmenopausal women who are not on hormone replacement therapy are at increased
risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middleaged woman who has never been pregnant would not have a risk potential as high as the older
woman who is not using hormone replacement therapy.
After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium),
the nurse assesses the client’s understanding. Which statement made by the client indicates a
correct understanding of the teaching?
a. “I will not take this drug with food or milk.”
b. “If I think I am pregnant, I will stop the drug.”
c. “An orange color in my urine should not alarm me.”
d. “I will drink two glasses of cranberry juice daily.”
ANS: C
Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think
they have blood in their urine when they see this. In addition, the urine can permanently stain
clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions
or needs while taking this medication.

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