Gastritis A. Rapid onset of mid-sternal discomfort.

B. Epigastric pain relieved by eating food

1. This refers to the inflammation of the gastric
C. Dyspepsia and hematemesis.
or stomach mucosa that can also be acute or
D. Nausea and projectile vomiting
chronic.
A. Gastrointestinal Intubation
7. Which of the following refers to the insertion
B. NGT
of a flexible tube into the stomach, beyond the
C. Gastritis
pylorus into the duodenum or the jejunum?
D. IBS
A. Gastritis
B. IBS
2. Nursing management of the patient with
C. Gastrointestinal Intubation
chronic gastritis includes teaching the patient
D. Gastrostomy
to:
A. maintain a bland diet with six small meals a
8. This refers to a large-bore tube inserted
day
through the mouth with a wide outlet for
B. take antacids before meals removal of gastric contents.
C. use NSAIDS instead of aspirin for pain relief A. Gastrostomy
D. eliminate alcohol and caffeine B. Orogastric Tube
C. Pipe Tube
3. "Which of the following types of gastritis is D. PVC Tube
associated with Helicobacter pylori and
duodenal ulcers? 9. Which of the following refers to a surgical
A. Erosive (hemorrhagic) gastritis procedure in which an opening is created into
B. Fundic gland gastritis (type A) the stomach for the purpose of administering
C. Antral gland gastritis (type B) food and fluids.
D. Aspirin-induced gastric ulcer A. Jejustomy
B. Orogastric Tube
4. The nurse is caring for a male client with a C. NGT
diagnosis of chronic gastritis. The nurse D. Gastrostomy
monitors the client knowing that this client is at
risk for which vitamin deficiency? 10. This refers to a method of providing
A. Vitamin A nutrients to the body by an intravenous route.
B. Vitamin B12 A. Jejustomy
C. Vitamin C B. Orogastric Tube
D. Vitamin E C. NGT
D. Parenteral Nutrition
5. Which of the following types of gastritis is
associated with Helicobacter pylori and 11. The nurse is preparing to administer
duodenal ulcers? medication through a nasogastric tube that is
A. Erosive (hemorrhagic) gastritis connected to suction. To administer the
B. Fundic gland gastritis (type A) medication, the nurse should take which
C. Antral gland gastritis (type B) action?
D. Aspirin-induced gastric ulcer A. Position the client supine to assist in
medication absorption.
6. "The nurse is caring for the client diagnosed B. Aspirate the nasogastric tube after
with chronic gastritis. Which symptom(s) would medication administration to maintain patency.
support this diagnosis?
C. Clamp the nasogastric tube for 30 to 60 D. Pull back on the tube and wait until the
minutes following administration of the respiratory distress subsides.
medication.
D. Change the suction setting to low 15. This method of tube feeding is administered
intermittent suction for 30 minutes after by gravity into the stomach through a large
medication syringe.
Administration. A. Cyclic feeding
B. Continuous feeding
12. The registered nurse is preparing to insert a C. Intermittent gravity drip feeding method
nasogastric tube in an adult client. To D. Bolus feeding
determine the accurate measurement of the
length of the tube to be inserted, the nurse 16. This method of tube feeding is given over 8
should take which action?
to 18 hours.
A. Mark the tube at 10 inches (25.5 cm).
A. Cyclic feeding
B. Mark the tube at 32 inches (81 cm).
B. Continuous feeding
C. Place the tube at the tip of the nose and
C. Intermittent gravity drip feeding method
measure by extending the tube to the earlobe
D. Bolus feeding
and then down to the xiphoid process.
D. Place the tube at the tip of the nose and
17. This method of tube feeding requires
measure by extending the tube to the earlobe
and then down to the top of the sternum. administering feedings over 30 minutes at
designated intervals by a reservoir enteral bag
13. The nurse checks for residual before and tubing.
administering a bolus tube feeding to a client A. Cyclic feeding
with a nasogastric tube and obtains a residual B. Continuous feeding
amount of 150 mL. What is the most C. Intermittent gravity drip feeding method
appropriate action for the nurse to take? D. Bolus feeding
A. Hold the feeding and reinstill the residual
amount. 18. This method of tube feeding wherein the
B. Reinstill the amount and continue with delivery of feedings incrementally over long
administering the feeding. periods.
C. Elevate the client's head at least 45 degrees A. Cyclic feeding
and administer the feeding. B. Continuous feeding
D. Discard the residual amount and proceed C. Intermittent gravity drip feeding method
with administering the feeding. D. Bolus feeding

14. The nurse is inserting a nasogastric tube in 19. This refers to one of the most common
an adult client. During the procedure, the client gastrointestinal problems that results from
begins to cough and has difficulty breathing. functional disorder of intestinal motility.
A. Gastrointestinal intubation
What is the most appropriate action?
B. Malabsorption
A. Insert the tube quickly.
C. Gastritis
B. Notify the health care provider immediately.
D. Irritable Bowel Syndrome
C. Remove the tube and reinsert it when the
respiratory distress subsides.
20. Which of the following refers to the inability C. Ask the client to identify other situation in
of the digestive system to absorb one or more which the client changed health care habits
of the major vitamins, minerals and nutrients. D. Provide reassurance that the client will be
A. Gastrointestinal intubation able to implement all aspects of the plan
B. Malabsorption successfully.
C. Gastritis
D. Irritable Bowel Syndrome 5. The client has been taking magnesium
hydroxide (milk of magnesia) to control hiatal
Hiatal Hernia hernia symptoms. The nurse should assess the
client for which of the following conditions are
1. Cimetidine (Tagamet) may also be used to most commonly associated with the ongoing
treat hiatal hernia. The nurse should use of magnesium-based antacids?
understand that this drug is used to prevent A. anorexia
which of the following? B. weight gain
A. Esophageal Reflux C. diarrhea
B. Dysphagia
D. constipation
C. Esophagitis
D. Ulcer Formation
6. Which of the following lifestyle modifications
2. The nurse is obtaining a health history from a should the nurse encourage the client with
client who has a sliding hiatal hernia associated hiatal hernia to include in ADLs?
with reflux. The nurse should ask the client A. Daily aerobic exercise
about the presence of which of the following B. eliminating smoking and alcohol use
symptoms? C. balancing activity and rest
A. Heartburn D. avoiding high-stress situation
B. Jaundice
C. Anorexia
D. Stomatitis 7. In developing a teaching plan for the client
with a hiatal hernia, the nurse's assessment of
3. Which of the following factors would most
which work-related factors would be most
likely contribute to the development of a
useful?
client’s hiatal hernia?
A. Having a sedentary desk job. A. number and length of breaks
B. Being 5 feet, 3 inches tall and weighing 190 B. body mechanics used in lifting
lb. C. temperature in the work area
C. Using laxatives frequently. D. Cleansing solvents used
D. Being 40 years old.
8. The nurse instructs the client on health
4. Which of the following nursing interventions maintenance activities to help control
would most likely promote self-care behaviors symptoms from a hiatal hernia. Which of the
in the client with a hiatal hernia? following statements would indicate the client
A. Introduce the client to other people who are has understood the instructions?
successfully managing their care. A. "I'll avoid lying down after a meal."
B. Include the client's daughter in the teaching B. "I can still enjoy my potato chips and cola at
so that she can help implement the plan bedtime."
C. "I wish I didn't have to give up swimming."
D. "If I wear a girdle, I'll have more support for
my stomach."

9. The client asks the nurse if surgery is needed 13. This refers to the part of the stomach that
to correct a hiatal hernia. Which reply by the protrudes through the esophageal hiatus of the
nurse would be the MOST accurate? diaphragm into the thoracic cavity.
A. "Surgery is usually required, although A. Impaired Esophageal Motility
medical treatment is attempted first." B. Hiatal Hernia
B. "Hiatal hernia symptoms can usually be C. GERD
successfully managed with diet modification, D. PUD
medications, and lifestyle changes."
C. "Surgery is not performed for this type of
hernia." GERD
D. "A minor surgical procedure to reduce the
size of the diaphragmatic opening will probably 1. The nurse should instruct the client to avoid
be planned." which of the following drugs while taking
metoclopramide hydrochloride (Reglan)?
10. What type of hiatal hernia more commonly A. Antacids
leads to strangulation as a severe complication? B. Antihypertensives
A. Sliding hiatal hernias C. Anticoagulants
B. Hernias do not strangulate D. Alcohol
C. Paraesophageal hiatal hernias
D. Both types equally lead to strangulation 2. The male client tells the nurse he has been
experiencing "heartburn" at night that awakens
11. A 55-year-old male presents to his PCP with him. Which assessment question should the
a chief complaint of heartburn and difficulty nurse ask?
swallowing. His provider notes a congenital A. "How much weight have you gained
short esophagus was discovered on previous recently?"
CXR. What does this discovery put the patient at B. "What have you done to alleviate your
risk for? heartburn?"
A. Obesity C. "Do you consume a lot of milk and dairy
B. Sliding hiatal hernia products?"
C. GERD D. "Have you been around anyone with a
D. Gastritis stomach virus?"

12. Symptoms of a hiatal hernia include all of 3. The nurse caring for a client diagnosed with
the following, EXCEPT: GERD writes about the client's problem of
A. Asymptomatic "behavior modification." Which intervention
B. Regurgitation should be included for this problem?
C. Constipation A. Teach the client to sleep with a foam wedge
D. Dysphagia under the head
B. Encourage the client to decrease the amount
of smoking
C. Instruct the client to take over-the-counter C. Instruct the client to maintain a right lateral
medication for relief of pain side-lying position and take antacids before
D. Discuss the need to attend Alcoholics meals
Anonymous to quit drinking D. Elevate the head of the bed 30 degrees and
discuss lifestyle modifications with the client
4. The nurse is preparing a client diagnosed with
GERD for discharge following an 7. The nurse is caring for an adult client
esophagogastroduodenoscopy. Which diagnosed with GERD. Which condition is the
statement indicates the client understands the most common comorbid disease associated
discharge instructions? with GERD?
A. "I should not eat for at least one (1) day A. Adult-onset asthma
following this procedure" B. Pancreatitis
B. "I can lie down whenever I want after a meal. C. Peptic ulcer disease
It won't make a difference" D. Increased gastric emptying
C. "The stomach contents won't bother my
esophagus but will make me nauseous" 8. The nurse is preparing a client diagnosed with
D. "I should avoid orange juice and eating GERD for surgery. Which information warrants
tomatoes until my esophagus heals" notifying the HCP?
A. The client's Bernstein esophageal test was
positive
B. The client's abdominal x-ray shows a hiatal
hernia
5. The nurse is planning the care of a client C. The client's WBC count is 14,000/mm^3
diagnosed with lower esophageal sphincter D. The client's hemoglobin is 13.8 g/dL
dysfunction. Which dietary modifications should
be included in the plan of care? 9. Which statement made by the client indicates
A. Allow any of the client's favorite foods as to the nurse that the client may be experiencing
long as the amount is limited GERD?
B. Have the client perform eructation exercises A. "My chest hurts when I walk up the stairs in
several times a day my home:
C. Eat four (4) to six (6) small meals a day and B. "I take antacid tablets with me wherever I
limit fluids during mealtimes go"
D. Encourage the client to consume a glass of C. "My spouse tells me I snore very loudly at
red wine with one (1) meal a day night"
D. "I drink six (6) to seven (7) soft drinks every
6. The nurse is caring for a client diagnosed with day
GERD. Which nursing intervention should be
implemented? 10. The nurse is performing an admission
A. Place the client prone in bed and administer assessment on a client diagnosed with GERD.
nonsteroidal anti-inflammatory medications Which signs and symptoms would indicate
B. Have the client remain upright at all times GERD?
and walk for 30 minutes three (3) times a week A. Pyrosis, water brash, and flatulence
B. Weight loss, dysarthria, and diarrhea
C. Decreased abdominal fat, proteinuria, and considered successful if the client decreases the
constipation intake of which of the following foods?
D. Midepigastric pain, positive H. pylori test, A. fats
and melena B. high-sodium foods
C. Carbohydrates
11. Which disease is the client diagnosed with D. high calcium foods
GERD at a greater risk for developing?
A. Twenty blood stools a day 16. Which of the following dietary measures
B. Oral temperature of 102 degrees Fahrenheit would be useful in preventing Esophageal
C. Esophageal cancer reflux?
D. Gastric cancer A. Eating small, frequent meals
B. increasing fluid intake
12. Which of the following instructions should C. avoiding air swallowing with meals
the nurse include in the teaching plan for a D. Adding a bedtime snack to the dietary plan
client who is experiencing gastroesophageal
reflux disease (GERD)? 17. The nurse is obtaining a health history from
A. Limit caffeine intake to two cups of coffee a client who has a sliding hiatal hernia
per day associated with reflux. The nurse should ask the
B. Do not lie down for 2 hours after eating client about the presence of which of the
C. Follow a low-protein diet following symptoms?
D. Take medications with milk to decrease A. Heartburn
irritation B. Jaundice
C. Anorexia
13. A client who has been diagnosed with GERD D. Stomatitis
has heartburn. To decrease the heartburn, the
nurse should instruct the client to eliminate
which of the following items from the diet?
A. Lean beef
B. Air-popped popcorn 18. Your patient, who is presenting with signs
C. Hot chocolate and symptoms of GERD, is scheduled to have a
D. Raw vegetables test that assesses the function of the
esophagus' ability to squeeze food down into
14. The client with GERD has a chronic cough. the stomach and the closure of the lower
This symptom may be indicative of which of the esophageal sphincter. The patient asks you,
following? "What is the name of the test I'm having later
A. Development of laryngeal cancer today?" You tell the patient the name of the
B. Irritation of the esophagus test is:*
C. Esophageal scar tissue formation A. Lower Esophageal Gastrointestinal Series
D. Aspiration of gastric contents B. Transesophageal echocardiogram
C. Esophageal manometry
15. The client attends two sessions with the D. Esophageal pH monitoring
dietitian to learn about diet modifications to
minimize GERD. The teaching would be 19. After dinner time, during hourly rounding, a
patient awakes to report they feel like "food is
coming up" in the back of their throat and that c. Give up jogging and substitute a less
there is a bitter taste in their mouth. What demanding hobby.
nursing intervention will you perform next? d. Incorporate periods of physical and mental
A. Perform deep suctioning rest in his daily schedule.
B. Assist the patient into the Semi-Fowler's
position
C. Keep the patient NPO 2. A client with a peptic ulcer reports epigastric
D. Instruct the patient to avoid milk products pain that frequently awakens her during the
night. The nurse should instruct the client to do
20. After providing education to a patient with which activities? Select all that apply.
GERD. You ask the patient to list 4 things they 1. Obtain adequate rest to reduce stimulation.
can do to prevent or alleviate signs and 2. Eat small, frequent meals throughout the
symptoms of GERD. Which statement is day.
INCORRECT? 3. Take all medications on time as ordered.
A. "It is best to try to consume small meals 4. Sit up for one hour when awakened at night.
throughout the day than eat 3 large ones." 5. Stay away from crowded areas.
B. "I'm disappointed that I will have to limit my
intake of peppermint and spearmint because I A. 1, 2, 3 and 4
love eating those types of hard candies." B. 2, 3, 4 and 5
C. "It is important I avoid eating right before C. 2, 4 and 5 only
bedtime." D. 3 and 5 only
D. "I will try to lie down after eating a meal to
help decrease pressure on the lower 3. A client with peptic ulcer disease reports that
esophageal sphincter." he has been nauseated most of the day and is
now feeling light-headed and dizzy. Based upon
21. Which of the following refers to a backflow these findings, which nursing actions would be
of gastric duodenal contents into the most appropriate for the nurse to take? Select
esophagus? all that apply.
A. Impaired Esophageal Motility a. Administering an antacid hourly until nausea
B. Hiatal Hernia subsides.
C. GERD b. Monitoring the client’s vital signs.
D. PUD c. Notifying the physician of the client’s
symptoms.
Peptic Ulcer Disease d. Initiating oxygen therapy. Reassessing the
client in an hour.
1. A client with a peptic ulcer has been
instructed to avoid intense physical activity and A. 1, 2, 3 and 4
stress. Which strategy should the client B. 2, 3, 4 and 5
incorporate into the home care plan? C. 2, 4 and 5 only
a. Conduct physical activity in the morning so D. 2 and 3 only
that he can rest in the afternoon.
b. Have the family agree to perform the 4. The nurse finds a client who has been
necessary yard work at home. diagnosed with a peptic ulcer surrounded by
papers from his briefcase and arguing on the
telephone with a coworker. The nurse’s a. The client has not been including enough
response to observing these actions should be fiber in his diet.
based on knowledge that: b. The client needs to increase his daily exercise.
a. Involvement with his job will keep the client c. The client is experiencing an adverse effect of
from becoming bored. the aluminum hydroxide.
b. A relaxed environment will promote ulcer d. The client has developed a gastrointestinal
healing. obstruction.
c. Not keeping up with his job will increase the
client’s stress level. 8. A client is taking an antacid for treatment of a
d. Setting limits on the client’s behavior is an peptic ulcer. Which of the following statements
important nursing responsibility. best indicates that the client understands how
to correctly take the antacid?
5. A client with a peptic ulcer has been a. “I should take my antacid before I take my
instructed to avoid intense physical activity and other medications.”
stress. Which strategy should the client b. “I need to decrease my intake of fluids so
incorporate into the home care plan? that I don’t dilute the effects of my antacid.”
a. Conduct physical activity in the morning so c. “My antacid will be most effective if I take it
that he can rest in the afternoon. whenever I experience stomach pains.”
b. Have the family agree to perform the D. “It is best for me to take my antacid 1 to 3
necessary yard work at home. hours after meals.”
c. Give up jogging and substitute a less
demanding hobby. 9. Which of the following would be an expected
d. Incorporate periods of physical and mental outcome for a client with peptic ulcer disease?
rest in his daily schedule. The client will:
a. Demonstrate appropriate use of analgesics to
control pain.
6. A client is to take one daily dose of ranitidine b. Explain the rationale for eliminating alcohol
(Zantac) at home to treat her peptic ulcer. The from the diet.
client understands proper drug administration c. Verbalize the importance of monitoring
of ranitidine when she says that she will take hemoglobin and hematocrit every 3 months.
the drug at which of the following times? d. Eliminate contact sports from his or her life-
A. Before meals. style.
B. With meals.
C. At bedtime. 10. The client with peptic ulcer disease (PUD)
D. When pain occurs. asks the nurse whether licorice and slippery elm
might be useful in managing the disease. What
7. A client has been taking aluminum hydroxide is the nurse's best response?
(Amphojel) 30 mL six times per day at home to A. "No, they probably won't be useful. You
treat his peptic ulcer. He tells the nurse that he should use only prescription medications in
has been unable to have a bowel movement for your treatment plan."
3 days. Based on this information, the nurse B. "These herbs could be helpful. However, you
would determine that which of the following is should talk with your physician before adding
the most likely cause of the client’s them to your treatment regimen."
constipation?
C. "Yes, these are known to be effective in 14. A The client is experiencing bleeding related
managing this disease, but make sure you to peptic ulcer disease (PUD). Which nursing
research the herbs thoroughly before taking intervention is the highest priority?
them." A. Starting a large-bore intravenous (IV)
D. "No, herbs are not useful for managing this B. Administering intravenous (IV) pain
disease. You can use any type of over-the- medication
counter drugs though. They have been shown C. Preparing equipment for intubation
to be safe." D. Monitoring the client's anxiety level

11. A client with peptic ulcer disease tells the 15. The nurse is preparing to teach a client with
nurse that he has black stools, which he has not a peptic ulcer about the diet that should be
reported to his physician. Based on this followed after discharge. The nurse should
information, which nursing diagnosis would be explain that the diet will most likely consist of
appropriate for this client? which of the following?
A. Ineffective coping related to fear of diagnosis A. Bland foods.
of chronic illness. B. High-protein foods.
B. Deficient knowledge related to unfamiliarity C. Any foods that are tolerated.
with significant signs and symptoms. D. Large amounts of milk.
C. Constipation related to decreased gastric
motility. 16. The nurse finds a client who has been
D. Imbalanced nutrition: Less than body diagnosed with a peptic ulcer surrounded by
requirements related to gastric bleeding. papers from his briefcase and arguing on the
telephone with a coworker. The nurse's
12. A client with peptic ulcer disease is taking response to observing these actions should be
ranitidine (Zantac). What is the expected based on knowledge that:
outcome of this drug? A. Involvement with his job will keep the client
A. Heal the ulcer. from becoming bored.
B. Protect the ulcer surface from acids. B. A relaxed environment will promote ulcer
C. Reduce acid concentration. healing.
D. Limit gastric acid secretion. C. Not keeping up with his job will increase the
client's stress level.
13. The client with a history of peptic ulcer D. Setting limits on the client's behavior is an
disease is admitted into the intensive care unit important nursing responsibility.
with frank gastric bleeding. Which priority
intervention should the nurse implement? 17. A client with a peptic ulcer has been
A. Maintain a strict record of intake and output instructed to avoid intense physical activity and
B. Insert a nasogastric tube and begin saline stress. Which strategy should the client
lavage incorporate into the home care plan?
C. Assist the client with keeping a detailed A. Conduct physical activity in the morning so
calorie count that he can rest in the afternoon.
D. Provide a quiet environment to promote rest B. Have the family agree to perform the
necessary yard work at home.
C. Give up jogging and substitute a less
demanding hobby.
D. Incorporate periods of physical and mental 21. Which of the following would be an
rest in his daily schedule. expected outcome for a client with peptic ulcer
disease? The client will:
18. A client is to take one daily dose of A. Demonstrate appropriate use of analgesics to
ranitidine (Zantac) at home to treat her peptic control pain.
ulcer. The client understands proper drug B. Explain the rationale for eliminating alcohol
administration of ranitidine when she says that from the diet.
she will take the drug at which of the following C. Verbalize the importance of monitoring
times? hemoglobin and hematocrit every 3 months.
A. Before meals. D. Eliminate contact sports from his or her
B. With meals. lifestyle.
C. At bedtime.
D. When pain occurs. 22. The nurse is caring for a client diagnosed
with rule out peptic ulcer disease. Which test
19. A client has been taking aluminum confirms this diagnosis?
hydroxide (Amphojel) 30 mL six times per day at A. Esophagogastroduodenoscopy
home to treat his peptic ulcer. He tells the nurse B. Magnetic resonance imaging
that he has been unable to have a bowel C. Occult blood test
movement for 3 days. Based on this D. Gastric acid stimulation.
information, the nurse would determine which
of the following is the most likely cause of the 23. Which specific data should the nurse obtain
client's constipation? from the client who is suspected of having
A. The client has not been including enough peptic ulcer disease?
fiber in his diet. A. History of side effects experienced from all
B. The client needs to increase his daily medications
exercise. B. Use of non-steroidal anti-inflammatory drugs
C. The client is experiencing an adverse effect of (NSAIDs)
the aluminum hydroxide. C. Any known allergies to drugs and
D. The client has developed a gastrointestinal environmental factors
obstruction. D. Medical histories of at least 3 generations

20. A client is taking an antacid for treatment of 24. Which physical examination should the
a peptic ulcer. Which of the following nurse implement first when assessing the client
statements best indicates that the client diagnosed with peptic ulcer disease?
understands how to correctly take the antacid? A. Auscultate the client's bowel sounds in all
A. "I should take my antacid before I take my four quadrants
other medications." B. Palpate the abdominal area for tenderness
B. "I need to decrease my intake of fluids so C. Percuss the abdominal borders to identify
that I don't dilute the effects of my antacid." organs
C. "My antacid will be most effective if I take it D. Assess the tender area progressing to
whenever I experience stomach pains." nontender
D. "It is best for me to take my antacid 1 to 3
hours after meals." 25. Which problems should the nurse include in
the plan of care for the client diagnosed with
peptic ulcer disease to observe for physiological B. Hiatal Hernia
complications? C. GERD
A. Alteration in bowel elimination patterns D. PUD
B. Knowledge deficit in the causes of ulcers
C. Inability to cope with changing family roles 30. This refers to an excavation or ulceration
D. Potential for alteration in gastric emptying that penetrates the mucosal wall of the
Gastrointestinal tract.
26. Which expected outcome should the nurse A. Impaired Esophageal Motility
include for a client diagnosed with peptic ulcer B. Hiatal Hernia
disease? C. GERD
A. The client's pain is controlled with the use of D. PUD
NSAIDs
B. The client maintains lifestyle modifications
C. The client has no signs and symptoms of Hepatic Dysfunction Manifestations
hemoptysis
D. The client takes antacids with each meal 1. The nurse is assessing a client with cirrhosis
who has developed hepatic encephalopathy.
27. The nurse has been assigned to care for a The nurse should notify the physician of a
client diagnosed with peptic ulcer disease. decrease in which lab serum that is a potential
Which assessment data require further precipitating factor for hepatic
intervention? encephalopathy?
A. Bowel sour s auscultated 15 times in 1 A. Aldosterone
minute B. Creatinine
B. Belching after eating a heavy and fatty meal C. Potassium
late at night D. Protein
C. A decrease in systolic BP of 20 mm Hg from
lying to sitting 2. A client has advanced cirrhosis of the liver.
D. A decreased frequency of distress located in The client’s spouse asks the nurse why his
the epigastric region abdomen is swollen, making it very difficult for
him to fasten his pants. How should the nurse
28. The nurse has administered an antibiotic, a respond to provide the most accurate
proton pump inhibitor, and Pepto- Bismol for explanation of the disease process?
peptic ulcer disease secondary to H. pylori. a. “He must have been eating too many foods
Which data would indicate to the nurse the with salt in them. Salt pulls water with it.”
medications are effective? b. “The swelling in his ankles must have moved
A. A decrease in alcohol intake up closer to his heart so the fluid circulates
B. Maintaining a bland diet better.”
C. A return to previous activities c. “He must have forgotten to take his daily
D. A decrease in gastric distress water pill.”
d. “Blood is not able to flow readily through the
29. This disorder is frequently referred to as liver now, and the liver cannot make protein to
gastric, duodenal, or esophageal ulcer, keep fluid inside the blood vessels.”
depending on its location.
A. Impaired Esophageal Motility
3. A nurse is developing a care plan for a client c. Prepare for a paracentesis.
with hepatic encephalopathy. Which of the d. Raise the head of the bed.
following are goals for the care for this client?
Select all that apply. 7. Which of the following positions would be
1. Preventing constipation. appropriate for a client with severe ascites?
2. Administering lactulose (Cephulac). A. Fowler’s
3. Monitoring coordination while walking. B. Side-lying
4. Checking the pupil reaction. C. Reverse Trendelenburg
5. Providing food and fluids high in D. Sim’s.
carbohydrate.
6. Encouraging physical activity. 8. The nurse is planning care for a client being
admitted with bleeding esophageal varices.
A. 1, 2, 3, 4 and 5 Vital signs are: Pulse 100; respiratory rate 22;
B. 2, 4, and 6 only and blood pressure 100/58. The nurse should
C. 1, 2, 4 and 5 only prepare the client for which of the following?
D. 2, 3 and 4 only Select all that apply.
E. All of the above 1. Administration of intravenous Octreotide
(Sandostatin).
4. The nurse is assessing a client who is in the 2. Endoscopy.
early stages of cirrhosis of the liver. Which 3. Administration of a blood product.
focused assessment is appropriate? 4. Minnesota tube insertion.
a. Peripheral edema. 5. Trans jugular intrahepatic portosystemic
b. Ascites. shunt (TIPS) procedure.
c. Anorexia. 6. Immediate endotracheal intubation.
d. Jaundice.
A. 1, 3 and 5
5. A client with cirrhosis begins to develop B. 1, 2, 4 and 6
ascites. Spironolactone (Aldactone) is C. 1, 3, 4 and 6
prescribed to treat the ascites. The nurse should D. 1, 2 and 3
monitor the client closely for which of the
following drug-related adverse effects? 9. The nurse monitors a client with cirrhosis for
A. Constipation the development of hepatic encephalopathy.
B. Hyperkalemia Which of the following would be an indication
C. Irregular Pulse that hepatic encephalopathy is developing?
D. Dysuria a. Decreased mental status.
b. Elevated blood pressure.
6. The nurse is reviewing the chart information c. Decreased urine output.
for a client with increased ascites. The data d. Labored respirations.
include: temperature 37.2° C; heart rate 118;
shallow respirations 26; blood pressure 128/76; 10. A client’s serum ammonia level is elevated,
and SpO2 89% on room air. Which action should and the physician orders 30 mL of lactulose
receive priority by the nurse? (Cephulac). Which of the following is an adverse
a. Assess heart sounds. effect of this drug?
b. Obtain an order for blood cultures. a. Increased urine output.
b. Improved level of consciousness. 15. The nurse should institute which of the
c. Increased bowel movements. following measures to prevent transmission of
d. Nausea and vomiting. the hepatitis C virus to health care personnel?
a. Administering hepatitis C vaccine to all health
11. The nurse is providing discharge instructions care personnel.
for a client with cirrhosis. Which of the b. Decreasing contact with blood and blood-
following statements best indicates that the contaminated fluids.
client has under- stood the teaching? c. Wearing gloves when emptying the bedpan.
a. “I should eat a high-protein, high- d. Wearing a gown and mask when providing
carbohydrate diet to provide energy.” direct care.
b. “It is safer for me to take acetaminophen
(Tylenol) for pain instead of aspirin.” 16. The nurse is assessing a client with chronic
c. “I should avoid constipation to decrease hepatitis B who is receiving Lamivudine (Epivir).
chances of bleeding.” What information is most important to
d. “If I get enough rest and follow my diet, it is communicate to the physician?
possible for my cirrhosis to be cured.” a. The client’s daily record indicates a 3 kg
weight gain over 2 days.
12. The nurse is preparing a client for a b. The client is complaining of nausea.
paracentesis for ascites. The nurse should: c. The client has a temperature of 99° F orally.
a. Have the client void immediately before the d. The client has fatigue
procedure.
b. Place the client in a side-lying position. 17. The nurse is assessing a client with hepatitis
c. Initiate an I.V. line to administer sedatives. and notices that the AST and ALT lab values
d. Place the client on nothing-by-mouth (NPO) have increased. Which of the following
status 6 hours before the procedure. statements by the client requires further
instruction by the nurse?
13. Which of the following interventions should a. “I require increased periods of rest.”
the nurse anticipate incorporating into the b. “I follow a low-fat, high carbohydrate diet.”
client’s plan of care when hepatic c. “I eat dry toast to relieve my nausea.”
encephalopathy initially develops? d. “I take acetaminophen (Tylenol) for arthritis
a. Inserting a nasogastric (NG) tube. pain.”
b. Restricting fluids to 1,000 mL/day.
c. Administering I.V. salt-poor albumin. 18. College freshman are participating in a study
d. Implementing a low-protein diet. abroad program. When teaching them about
hepatitis B, the nurse should instruct the
14. A client with ascites and peripheral edema is students on:
at risk for impaired skin integrity. To prevent a. Water sanitation.
skin breakdown, the nurse should: b. Single dormitory rooms.
a. Institute range-of-motion (ROM) exercise c. Vaccination for hepatitis D
every 4 hours. d. Safe sexual practices.
b. Massage the abdomen once a shift.
c. Use an alternating air pressure mattress. 19. The nurse is planning a home visit for a
d. Elevate the lower extremities. client with hepatitis A. In order to prevent
transmission the nurse should focus teaching d. Intensify routine exercise and increase
on: strength.
a. Proper food handling.
b. Insulin syringe disposal. 23. The nurse develops a teaching plan for the
c. Alpha-interferon. client about how to prevent the transmission of
d. Use of condoms. hepatitis A. Which of the following discharge
instructions is appropriate for the client?
a. Spray the house to eliminate infected insects.
b. Tell family members to try to stay away from
the client.
c. Tell family members to wash their hands
20. A client who is recovering from hepatitis A frequently.
has fatigue and malaise. The client asks the d. Disinfect all clothing and eating utensils.
nurse, “When will my strength return?” Which
of the following responses by the nurse is most 24. The nurse assesses that the client with
appropriate? hepatitis is experiencing fatigue, weakness, and
a. “Your fatigue should be gone by now. We will a general feeling of malaise. The client tires
evaluate you for a secondary infection.” rapidly during morning care. Based on this
b. “Your fatigue is an adverse effect of your information, which of the following would be an
drug therapy. It will disappear when your appropriate nursing diagnosis?
treatment regimen is complete.” a. Impaired physical mobility related to malaise.
c. “It is important for you to increase your b. Self-care deficit related to fatigue.
activity level. That will help decrease your c. Ineffective coping related to long-term
fatigue.” illness.
d. “It is normal for you to feel fatigued. The d. Activity intolerance related to fatigue.
fatigue should go away in the next 2 to 4
months.” 25. What would be the nurse’s best response
to the client’s expressed feelings of isolation as
21. The nurse is developing a plan of care for a result of having hepatitis?
the client with viral hepatitis. The nurse should a. “Don’t worry. It’s normal to feel that way.”
instruct the client to: b. “Your friends are probably afraid of
a. Obtain adequate bed rest. contracting hepatitis from you.”
b. Increase fluid intake. c. “I’m sure you’re imagining that!”
c. Take antibiotic therapy as ordered. d. “Tell me more about your feelings of
d. Drink 8 oz of an electrolyte solution every isolation.”
day.
26. The nurse is preparing a community
22. The nurse should teach the client with viral education program about preventing hepatitis B
hepatitis to: infection. Which of the following would be
a. Limit caloric intake and reduce weight. appropriate to incorporate into the teaching
b. Increase carbohydrates and protein in the plan?
diet. A. Hepatitis B is relatively uncommon among
c. Avoid contact with others and live separately. college students.
B. Frequent ingestion of alcohol can predispose A. Deltoid
an individual to development of hepatitis B. B. Ventrogluteal
C. Good personal hygiene habits are most C. Dorsogluteal
effective at preventing the spread of hepatitis B. D. Vastus Lateralis
D. The use of a condom is advised for sexual
intercourse. 30. A public health nurse is caring for a 10-year-
old child who is diagnosed with hepatitis A. The
27. A nurse admits a male client to a hospital nurse is instructing the parents to avoid giving
with exacerbation of asthma. During the their child oral medications. Which is the
admission history, the nurse learns that the nurse’s rationale for giving this instruction?
client has a history of chronic hepatitis C. Which a. The child does not need pain medications
precautions should the nurse plan to implement because there is no pain associated with Hep A.
based on the transmission of the hepatitis C b. The medication of choice is antibiotics, and
virus? the child will be on those only while
A. Airborne hospitalized.
B. Contact c. Normal medication doses may become
C. Droplet dangerous due to the liver’s inability to detoxify
D. Standard and excrete them.
d. The foods provided will contain all of the
28. During the emergency insertion of a central natural substances the child will need for
venous line in a client diagnosed with hepatitis recovery.
B (HBV), a nurse suffers a needle-stick injury
from a blood-contaminated needle. The nurse SIADH/DI
goes directly to the hospital’s occupational
health service. Which immediate treatment 1. A patient arrives at the ER and is unable to
should the nurse anticipate receiving? give you a health history due to altered mental
a. Administration of hepatitis B immune status. The family reports the patient has
globulin (HBIG) and initiation of the hepatitis gained over 10 lbs in 1 week and says it is
vaccine if the nurse has not been previously mainly "water" weight. In addition, they report
vaccinated the patient hasn't been able to urinate or eat
b. Administration of hepatitis B immune within the past week as well and was recently
globulin (HBIG) diagnosed with small cell lung cancer. On
c. Blood tests for the presence of hepatitis B assessment, you note the patient's HR is 115
antigens and administration of HBIG 1 week and BP 180/92. Patient sodium level is 90.
later Which of the following conditions do you
d. Blood tests for the presence of hepatitis B suspect the patient is most likely presenting
antigens and treatment with HBIG if the tests with?
are positive A. SIADH
B. Diabetes Insipidus
29. A clinic nurse is administering monovalent C. Addison's Disease
Hep B (hepatitis B vaccine) intramuscularly to a D. Fluid Volume Deficit
new- born prior to hospital discharge. Which
site is best for the nurse to plan to administer [Link] of the following signs and symptoms is
the injection? NOT expected with Diabetes Insipidus?
A. Polyuria 7. Where is the antidiuretic hormone
B. Polydipsia PRODUCED in the body?
C. Polyphagia A. Anterior pituitary gland
D. Extreme thirst B. Posterior pituitary gland
C. Hypothalamus
[Link] are developing a care plan for a patient D. Medulla
with SIADH. Which of the following would be a
potential nursing diagnosis for this patient? [Link] is the antidiuretic hormone SECRETED
A. Fluid volume overload in the body?
B. Fluid volume deficit A. Hypothalamus
C. Acute pain B. Thyroid
D. Impaired skin integrity C. Posterior Pituitary gland
D. Anterior pituitary gland
4. A patient with a mild case of diabetes
insipidus is started on Diabinese. What would [Link] outcome indicates that treatment of a
you include in your patient teaching with this male client with diabetes insipidus has been
patient? effective?
A. Signs and symptoms of hypoglycemia A. The heart rate is 126 beats/minute.
B. Restricting foods containing caffeine B. Blood pressure is 90/50 mm Hg.
C. Taking the medication on an empty stomach C. Urine output measures more than 200
D. Drinking 16 oz of water when taking the ml/hour.
medication D. Fluid intake is less than 2,500 ml/day.

[Link] patient is most at risk for developing 10.A male client with primary diabetes insipidus
Syndrome of Inappropriate Antidiuretic is ready for discharge on desmopressin
Hormone (SIADH) (DDAVP). Which instruction should nurse Lina
A. A patient diagnosed with small cell lung provide?
cancer. A. "You won't need to monitor your fluid intake
B. A patient whose kidney tubules are failing to and output after you start taking
reabsorb water. desmopressin."
C. A patient with a tumor on the anterior B. "You may not be able to use desmopressin
pituitary gland. nasally if you have nasal discharge or blockage."
D. A patient taking Declomycin. C. "Your condition isn't chronic, so you won't
need to wear a medical identification bracelet."
6.A patient with SIADH is undergoing IV D. "Administer desmopressin while the
treatment of a hypertonic IV solution of 3% suspension is cold."
saline and IV Lasix. Which of the following
nursing findings requires intervention? [Link] of these signs suggests that a male
A. Sodium level of 136. client with the syndrome of inappropriate
B. Patient reports urinating more frequently. antidiuretic hormone (SIADH) secretion is
C. Potassium level of 5.0. experiencing complications?
D. Assessment finding of crackles throughout A. Weight loss
the lung fields. B. Polyuria
C. Tetanic contractions
D. Neck vein distention C. Urine glucose.
D. Urine white blood cells.
12. A male client is admitted for treatment of
the syndrome of inappropriate antidiuretic [Link] nurse is discharging a client diagnosed
hormone (SIADH). Which nursing intervention is with diabetes insipidus. Which statement made
appropriate? by the client warrants further intervention?
A. Infusing I.V. fluids rapidly as ordered A. "I will keep a list of my medications in my
B. Restricting fluids wallet and wear a Medic Alert bracelet."
C. Administering glucose-containing I.V. fluids as B. "I should take my medication in the morning
ordered and leave it refrigerated at home."
D. Encouraging increased oral intake C. "I should weigh myself every morning and
record any weight gain."
13. When caring for a male client with diabetes D. "If I develop a tightness in my chest, I will call
insipidus, nurse Juliet expects to administer: my health-care provider."
A. 10% dextrose. 18. The client is admitted to the medical unit
B. vasopressin (Pitressin Synthetic). with a diagnosis of rule-out diabetes insipidus
C. furosemide (Lasix). (DI). Which instructions should the nurse teach
D. regular insulin. regarding a fluid deprivation test?
A. The client will be asked to drink 100 mL of
14. The anti-diuretic hormone is __________ in fluid as rapidly as possible and then will not be
Diabetes Insipidus and _________ in SIADH. allowed fluid for 24 hours.
A. absent, absent B. The client will be administered an injection of
B. low, high antidiuretic hormone, and urine output will be
C. high, low measured for four (4) to six (6) hours.
D. low, low C. The client will be NPO, and vital signs and
weights will be done hourly until the end of the
15. The client diagnosed with a pituitary tumor test.
developed syndrome of inappropriate D. An IV will be started with normal saline, and
antidiuretic hormone (SIADH). Which the client will be asked to try to hold the urine
interventions should the nurse implement? in the bladder until a sonogram can be done.
A. Assess for dehydration and monitor blood
glucose levels. 19. The nurse is planning the care of a client
B. Assess for nausea and vomiting and weigh diagnosed with syndrome of inappropriate
daily. antidiuretic hormone (SIADH). Which
C. Monitor potassium levels and encourage fluid interventions should be implemented? Select all
intake. that apply.
D. Administer vasopressin IV and conduct a fluid 1. Restrict fluids per health-care provider order.
deprivation test. 2. Assess level of consciousness every two (2)
hours.
[Link] laboratory value should be monitored 3. Provide an atmosphere of stimulation.
by the nurse for the client diagnosed with 4. Monitor urine and serum osmolality.
diabetes insipidus? 5. Weigh the client every three (3) day
A. Serum sodium.
B. Serum calcium
A. 1, 2, 3
B. 1, 2, 4 CVA/STROKE
C.1, 2, 5
D 1, 4, 5 1. The nurse is teaching a client about taking
prophylactic warfarin sodium (Coumadin).
[Link] nurse is caring for a client diagnosed Which statement indicates that the client
with diabetes insipidus (DI). Which intervention understands how to take the drug? Select all
should be implemented? that apply.
A. Administer sliding-scale insulin as ordered. 1. “The drug’s action peaks in 2 hours.”
B. Restrict caffeinated beverages. 2. “Maximum dosage is not achieved until 3 to 4
C. Check urine ketones if blood glucose is >250. days after starting the medication.”
D. Assess tissue turgor every four (4) hours. 3. “Effects of the drug continue for 4 to 5 days
after discontinuing the medication.”
21. The nurse is admitting a client diagnosed 4. “Protamine sulfate is the antidote for
with syndrome of inappropriate antidiuretic warfarin.”
hormone (SIADH). Which clinical manifestations 5. “I should have my blood levels tested
should be reported to the health-care provider? periodically.”
A. Serum sodium of 112 mEq/L and a headache.
B. Serum potassium of 5.0 mEq/L and a 2. Regular oral hygiene is essential for the client
heightened awareness. who has had a stroke. Which of the following
C. Serum calcium of 10 mg/dL and tented tissue nursing measures is not appropriate when
turgor. providing oral hygiene?
D. Serum magnesium of 1.2 mg/dL and large 1. Placing the client on the back with a small
urinary output. pillow under the head.
22. The male client diagnosed with syndrome of 2. Keeping portable suctioning equipment at the
inappropriate antidiuretic hormone (SIADH) bedside.
secondary to cancer of the lung tells the nurse 3. Opening the client’s mouth with a padded
he wants to discontinue the fluid restriction and tongue blade.
does not care if he dies. Which action by the 4. Cleaning the client’s mouth and teeth with a
nurse is an example of the ethical principle of toothbrush.
autonomy?
A. Discuss the information the client told the 3. A client arrives in the emergency department
nurse with the health-care provider and with an ischemic stroke and receives tissue
significant other. plasminogen activator (t-PA) administration.
B. Explain it is possible the client could have a The nurse should first:
seizure if he drank fluid beyond the restrictions. 1. Ask what medications the client is taking.
C. Notify the health-care provider of the client's 2. Complete a history and health assessment.
wishes and give the client fluids as desired. 3. Identify the time of onset of the stroke.
D. Allow the client an extra drink of water and 4. Determine if the client is scheduled for any
explain the nurse could get into trouble if the surgical procedures.
client tells the health-care provider.
4. During the first 24 hours after thrombolytic
treatment for an ischemic stroke, the primary
goal is to control the client’s:
1. Pulse. 3. Lifting the client when moving the client up in
2. Respirations. bed.
3. Blood pressure. 4. Having the client help lift off the bed using a
4. Temperature. trapeze.

5. What is a priority nursing assessment in the 9. Which nursing intervention has been found
first 24 hours after admission of the client with to be the most effective means of preventing
a thrombotic stroke? plantar flexion in a client who has had a stroke
1. Cholesterol level. with residual paralysis?
2. Pupil size and pupillary response. 1. Place the client’s feet against a fi rm
3. Bowel sounds. footboard.
4. Echocardiogram. 2. Reposition the client every 2 hours.
3. Have the client wear ankle-high tennis shoes
6. A client with a hemorrhagic stroke is slightly at intervals throughout the day.
agitated, heart rate is 118, respirations are 22, 4. Massage the client’s feet and ankles
bilateral rhonchi are auscultated, SpO2 is 94%, regularly.
blood pressure is 144/88, and oral secretions
are noted. What order of interventions should 10. The nurse is planning the care of a
the nurse follow when suctioning the client to hemiplegic client to prevent joint deformities of
prevent increased intracranial pressure (ICP) the arm and hand. Which of the following
and maintain adequate cerebral perfusion? positions are appropriate?
1. Placing a pillow in the axilla so the arm is
1. Suction the airway away from the body.
2. Hyperoxygenate 2. Inserting a pillow under the slightly flexed
3. Suction the mouth arm so the hand is higher than the elbow.
4. Provide sedation 3. Immobilizing the extremity in a sling.
4. Positioning a hand cone in the hand so the
7. In planning care for the client who has had a fingers are barely flexed.
stroke, the nurse should obtain a history of the 5. Keeping the arm at the side using a pillow.
client’s functional status before the stroke
because? 11. For the client who is experiencing expressive
1. The rehabilitation plan will be guided by it. aphasia, which nursing intervention is most
2. Functional status before the stroke will help helpful in promoting communication?
predict outcomes. 1. Speaking loudly.
3. It will help the client recognize his physical 2. Using a picture board.
limitations. 3. Writing directions so client can read them.
4. The client can be expected to regain much of 4. Speaking in short sentences.
his functioning.
12. The nurse is teaching the family of a client
8. Which of the following techniques does the with dysphagia about decreasing the risk of
nurse avoid when changing a client’s position in aspiration while eating. Which of the following
bed if the client has hemiparalysis? strategies is not appropriate?
1. Rolling the client onto the side. 1. Maintaining an upright position.
2. Sliding the client to move up in bed.
2. Restricting the diet to liquids until swallowing 2. Charity.
improves. 3. Firmness.
3. Introducing foods on the unaffected side of 4. Encouragement.
the mouth. 5. Patience.
4. Keeping distractions to a minimum.
17. When communicating with a client who has
13. Which food-related behaviors are expected aphasia, which of the following nursing
in a client who has had a stroke that has left interventions is not appropriate?
him with homonymous hemianopia? 1. Present one thought at a time.
1. Increased preference for foods high in salt. 2. Encourage the client not to write messages.
2. Eating food on only half of the plate. 3. Speak with normal volume.
3. Forgetting the names of foods. 4. Make use of gestures.
4. Inability to swallow liquids.
14. A nurse is teaching a client who had a stroke 18. What is the expected outcome of
about ways to adapt to a visual disability. Which thrombolytic drug therapy for stroke?
does the nurse identify as the primary safety 1. Increased vascular permeability.
precaution to use? 2. Vasoconstriction.
1. Wear a patch over one eye. 3. Dissolved emboli.
2. Place personal items on the sighted side. 4. Prevention of hemorrhage.
3. Lie in bed with the unaffected side toward
the door. 19. A client who receives a diagnosis of right-
4. Turn the head from side to side when sided stroke should be assessed for risk factors
walking. of stroke during the initial hospitalization, and
measures should be instituted to lessen the
15. A client is experiencing mood swings after a client’s risk. A nurse should address these risk
stroke and often has episodes of tearfulness factors as a priority and institute measures
that are distressing to the family. Which is the because: SELECT ALL THAT APPLY.
best technique for the nurse to instruct family 1. one of every four strokes occurs as a
members to try when the client experiences a recurrent stroke.
crying episode? 2. the time period of greatest risk for a second
1. Sit quietly with the client until the episode is stroke is the first 30 days after ischemic
over. symptoms occur.
2. Ignore the behavior. 3. the potential for recovery continues for at
3. Attempt to divert the client’s attention. least 6 months after the initial stroke event.
4. Tell the client that this behavior is 4. controlling modifiable risk factors is too
unacceptable difficult for persons who have already
experienced a stroke.
16. The client who has had a stroke with 5. the resultant deficit will cause the client to
residual physical handicaps becomes deny or minimize that there is a problem.
discouraged by his physical appearance. What 6. most stroke victims develop depression and
approach to the client is best for the nurse to less interest in learning preventive measures as
use to help the client overcome his negative the recovery process lengthens.
self-concept? Select all that apply.
1. Helpfulness.
 2. Hyperthermia lowers the incidence of
20. A client who has had a stroke stares at a mortality.
nurse but does not attempt to verbally respond 3. A normal temperature will decrease the score
to the nurse’s questions. The client follows on the Glasgow coma scale.
instructions without any problems. The nurse 4. Hyperthermia increases the likelihood of a
understands that the client is displaying larger area of brain infarct
symptoms consistent with:
1. receptive aphasia. 23. A client is diagnosed with a stroke that
2. global aphasia. affects the right hemisphere of the brain. A
3. expressive aphasia. nurse, receiving report prior to the care of this
4. both receptive and expressive aphasia. client, should expect the client to have which
symptom?
21. A client is admitted to the intensive care 1. Right hemiparesis
unit with a severe stroke. The client is receiving 2. Expressive aphasia
a continuous intravenous insulin infusion 3. Poor impulse control
titrated according to hourly blood glucose 4. Marked anxiety when learning new tasks
results to control hyperglycemia. The client’s
spouse asks the nurse why the client is receiving 24. A client seeks medical attention at an
insulin when the client is not diabetic. Which emergency department after experiencing left-
explanations to the client’s spouse should the sided weakness and slurred speech. The client
nurse include? SELECT ALL THAT APPLY receives a diagnosis with an ischemic stroke and
1. “The body reacts to stress by producing is evaluated for treatment with thrombolytic
various hormones, which results in elevated therapy. A definite contraindication for
glucose levels.” thrombolytic therapy is:
2. “The body has less effective utilization of 1. a normal computed tomography (CT) scan of
glucose during serious illness.” the brain.
3. “Insulin lessens the likelihood of brain tissue 2. a serious head injury 4 weeks earlier.
becoming swollen.” 3. a history of diabetes mellitus.
4. “Use of insulin will decrease the likelihood of 4. the onset of neurological deficits 2 hours
the client becoming diabetic in the future.” earlier.
5. ‘The stroke affected the part of the brain that
controls the release of insulin.” 25. A client is admitted to an intensive care unit
6. “A side effect of the medications because of a leaking cerebral aneurysm. A
administered is the development of type 1 family member asks a nurse why the client is
diabetes mellitus.” awakened and questioned about his orientation
so frequently when he needs to rest. The nurse
22. A client with a deteriorating mental status answers the family member based on the
after suffering a stroke has a rectal temperature knowledge that the earliest sign of increased
of 102.3°F (39.1°C). For which reason should a intracranial pressure (ICP) is:
nurse initiate intervention to bring the 1. pupillary changes.
temperature to a normal level? 2. drop in the blood pressure.
1. A normal temperature will strengthen the 3. altered sensation.
client’s immune system against infection. 4. changes in the level of consciousness.
26. A nurse is orienting a new nurse to a unit. 2. The client remembers the events leading up
The experienced nurse evaluates that the new to the accident and what occurred during the
nurse understands information related to a accident.
stroke resulting from a subarachnoid 3. The client has experienced episodes of
hemorrhage when which points are addressed headache and dizziness on a daily basis since
by the new nurse? SELECT ALL THAT APPLY. the accident.
1. Subarachnoid hemorrhage is often associated 4. The client has difficulty concentrating and
with a rupture of a cerebral aneurysm. focusing while at work.
2. Subarachnoid hemorrhage usually occurs 5. The client reported a loss of consciousness
while the client is sleeping and is noticed when for a few seconds at the time of the injury. 6.
the client awakens. The client describes a funny taste in the mouth
3. Subarachnoid hemorrhage is accompanied by since the accident that is “disgusting.”
complaints of an extremely severe headache.
4. Subarachnoid hemorrhage may be treated HYPERTHYROIDISM/HYPOTHYROIDISM
with thrombolytic therapy if no 1.
contraindications exist.
5. Subarachnoid hemorrhage often results in
bloody cerebrospinal fluid (CSF).
6. Subarachnoid hemorrhage causes nuchal
rigidity

27. Following an industrial accident in which a

client sustained a severe craniocerebral trauma,
the client develops the complication of diabetes
insipidus (DI). A nurse suspects this
complication is occurring when observing which 1. K-dur® 20 mEq oral (PO) bid
symptom? 2. Calcium gluconate 4.5 mEq intravenously (IV)
1. Hyperglycemia 3. Dolasetron (Anzemet®) 12.5 mg IV as needed
2. Large amounts of urinary output 4. Levothyroxine (Synthroid®) 50 mcg PO daily
3. Elevated urine specific gravity
4. Decrease in level of consciousness 2. An agitated client is admitted to the
emergency department (ED) with tachycardia,
28. A client hits her head in a minor motor dyspnea, and intermittent chest palpitations.
vehicle accident and refuses medical attention The client has a blood pressure of 170/110 mm
at the time of the accident. The client makes an Hg and heart rate of 130 beats per minute. The
appointment with a primary care provider 6 client’s health history reveals thinning hair,
weeks later because of headaches. The primary recent 10-lb. weight loss, increased appetite,
care provider diagnoses the client with mild fine hand and tongue tremors, hyperreflexic
traumatic brain injury (TBI). Which details noted tendon reflexes, and smooth moist skin. A
by a nurse in the client’s history of the injury physician writes orders for the client. Which
support this diagnosis? SELECT ALL THAT APPLY. order should the nurse implement first?
1. The client has had no episodes of vomiting 1. Obtain 12-lead electrocardiogram (ECG).
after the accident.
2. Administer propranolol (Inderal®) 2 mg 4. Paresthesias
intravenously q10–15min or until symptoms are 5. Fine tremor of fingers and tongue
controlled. 6. Slowed mental processes
3. Administer propylthiouracil (PTU) 600 mg oral
loading dose followed by 200 mg orally q4h. 6. Which nursing diagnosis should a nurse
4. Obtain thyroid-stimulating hormone (TSH), include when developing a plan of care for a
free T4, and cardiac enzyme levels. client with hypothyroidism?
1. Diarrhea related to gastrointestinal
3. A clinic nurse is teaching a client who has hypermotility
been diagnosed with hypothyroidism. Which 2. Imbalance nutrition: less than body
instructions should the nurse provide regarding requirements related to calorie intake
the use of levothyroxine sodium (Synthroid®)? insufficient for metabolic rate
SELECT ALL THAT APPLY. 3. Activity intolerance related to increased
1. Take the medication 1 hour before or 2 hours metabolic rate
after breakfast. 4. Anxiety related to forgetfulness, slowed
2. Obtain a pulse rate before taking the speech, and impaired memory loss
medication, and call the clinic if the pulse rate is
greater than 100 beats per minute. 7. A female client is being treated with
3. Report adverse effects of the medication, radioactive iodine (RAI) therapy for an enlarged
including weight gain, cold intolerance, and thyroid gland. The client asks if there are any
alopecia. precautions that are needed during RAI therapy.
[Link] levothyroxine sodium (Synthroid®) as a Which is the nurse’s best response?
replacement hormone for diminished or absent 1. “No precautions are necessary. You receive
thyroid function. radiation in the form of a capsule that will
5. Have frequent laboratory monitoring to be target and destroy the thyroid tissue only.”
sure your levels of T3 and T4 decrease. 2. “Though a pregnancy test has confirmed that
you are not pregnant, use contraceptives or
4. A nurse is caring for a client who had a abstain from sexual intercourse to avoid
thyroidectomy 2 days ago. Based on the conceiving during treatment.”
findings of the client’s serum laboratory report, 3. “Because maximum effects may not be seen
which medication should the nurse plan to for 6 months, you will need to continue taking
administer first? the antithyroid medication and propranolol
1. K-dur® 20 mEq oral (PO) bid until the effects of radiation become apparent.”
2. Calcium gluconate 4.5 mEq intravenously (IV) 4. “Although RAI is usually effective, a few
3. Dolasetron (Anzemet®) 12.5 mg IV as needed individuals will need life-long thyroid hormone
4. Levothyroxine (Synthroid®) 50 mcg PO daily replacement due to posttreatment
hypothyroidism.”
5. A clinic nurse evaluates that a client’s
levothyroxine (Synthroid®) dose is too low 8. A nurse is teaching a client experiencing
when which findings are noted? SELECT ALL hypoparathyroidism resulting from a lack of
THAT APPLY. parathyroid hormone (PTH) about foods to
1. Increased appetite consume. Which should be included on a list of
2. Decreased sweating appropriate foods for a client experiencing
3. Apathy and fatigue hypoparathyroidism?
1. Dark green vegetables, soybeans, and tofu at work because I lose my temper very easily.”
2. Spinach, strawberries, and yogurt Which of the following responses by the nurse
3. Whole grain bread, milk, and liver would give the client the most accurate
4. Rhubarb, yellow vegetables, and fish explanation of her behavior?
1. “Your behavior is caused by temporary
9. The nurse is completing a health assessment confusion brought on by your illness.”
of a 42-year-old female with suspected Graves’ 2. “Your behavior is caused by the excess
disease. The nurse should assess this client for: thyroid hormone in your system.”
1. Anorexia. 3. “Your behavior is caused by your worrying
2. Tachycardia. about the seriousness of your illness.”
3. Weight gain. 4. “Your behavior is caused by the stress of
4. Cold skin. trying to manage a career and cope with
illness.”
10. When conducting a health history with a
female client with thyrotoxicosis, the nurse 14. Serum concentrations of thyroid hormones
should ask about which of the following and thyroid-stimulating hormone (TSH) are tests
changes in the menstrual cycle? ordered for the client with thyrotoxicosis.
1. Dysmenorrhea. Which of the following laboratory values are
2. Metrorrhagia. indicative of thyrotoxicosis?
3. Oligomenorrhea. 1. Elevated thyroid hormone concentrations
4. Menorrhagia. and normal TSH.
2. Elevated TSH and normal thyroid hormone
11. A 34-year-old female is diagnosed with concentrations.
hypothyroidism. The nurse should assess the 3. Decreased thyroid hormone concentrations
client for which of the following? Select all that and elevated TSH.
apply. 4. Elevated thyroid hormone concentrations
1. Rapid pulse. and decreased TSH.
2. Decreased energy and fatigue.
3. Weight gain of 10 lb. 15. Which of the following medications should
4. Fine, thin hair with hair loss. be available to provide emergency treatment if
5. Constipation. a client develops tetany after a subtotal
6. Menorrhagia. thyroidectomy?
1. Sodium phosphate.
12. Propylthiouracil (PTU) is prescribed for a 2. Calcium gluconate.
client with Graves’ disease. The nurse should 3. Echothiophate iodide.
teach the client to immediately report which of 4. Sodium bicarbonate.
the following?
1. Sore throat. 16. A 60-year-old female is diagnosed with
2. Painful, excessive menstruation. hypothyroidism. The nurse should assess the
3. Constipation. client for which of the following?
4. Increased urine output. 1. Tachycardia.
2. Weight gain.
13. A client with thyrotoxicosis says to the 3. Diarrhea.
nurse, “I am so irritable. I am having problems 4. Nausea.
 3. Diarrhea.
17. Appropriate nursing diagnoses for a client 4. Nausea.
with hypothyroidism would include which of the
following? 22. The nurse should teach the client to prevent
1. Risk for injury (corneal abrasion) related to corneal irritation from mild exophthalmos by:
incomplete closure of the eyelid. 1. Massaging the eyes at regular intervals.
2. Imbalanced nutrition: Less than body 2. Instilling an ophthalmic anesthetic as
requirements related to hypermetabolism. ordered.
3. Deficient fluid volume related to diarrhea. 3. Wearing dark-colored glasses.
4. Activity intolerance related to fatigue 4. Covering both eyes with moistened gauze
associated with the disorder pads.

18. The nurse asks the client to state her name

as soon as she regains consciousness
postoperatively after a subtotal thyroidectomy CUSHING’S & ADDISON’S
and at each assessment. The nurse does this to
monitor for signs of which of the following? 1. The nurse is assessing a client with possible
1. Internal hemorrhage. Cushing's syndrome. In a client with Cushing's
2. Decreasing level of consciousness. syndrome, the nurse would expect to find:
3. Laryngeal nerve damage. 1. Hypotension
4. Upper airway obstruction 2. Thick, coarse skin
3. deposits of adipose tissue in the trunk and
19. A client who has undergone a subtotal dorsocervical area
thyroidectomy is subject to complications in the 4. weight gain in arms and legs
first 48 hours after surgery. The nurse should
obtain and keep at the bedside equipment to: 2. The nurse is planning care for a 52-year-old
1. Begin total parenteral nutrition. male client in acute Addisonian crisis. Which
2. Start a cutdown infusion. nursing diagnosis should receive the highest
3. Administer tube feedings. priority?
4. Perform a tracheotomy. 1. Risk for Infection
2. Decreased cardiac output
20. Which of the following symptoms might 3. Impaired physical mobility
indicate that a client was developing tetany 4. Imbalanced nutrition: less than body
after a subtotal thyroidectomy? requirement
1. Pains in the joints of the hands and feet.
2. Tingling in the fingers. 3. During the first 24 hours after a client is
3. Bleeding on the back of the dressing. diagnosed with Addisonian crisis, which
4. Tension on the suture line intervention should the nurse perform
frequently
21. A 60-year-old female is diagnosed with 1. Weigh the client
hypothyroidism. The nurse should assess the 2. Test urine for ketones
client for which of the following? 3. Assess vital signs
1. Tachycardia. 4. Administer oral hydrocortisone
2. Weight gain.
4. A client is admitted to the health care facility 8. The nurse is caring for a client in acute
for evaluation for Addison's disease. Which Addisonian crisis. Which laboratory data would
laboratory test result best supports a diagnosis the nurse expect to find?
of Addison's disease? 1. hyperkalemia
1. BUN level of 12 mg/dl 2. reduced BUN
2. Blood glucose level of 90 mg/dl 3. hypernatremia
3. Serum sodium level of 134 mEq/L 4. Serum 4. Hyperglycemia
potassium level of 5.8 mEq/L
9. A client with Addison's disease comes to the
clinic for a follow-up visit. When assessing this
5. A client with Addison's disease is scheduled client, the nurse should stay alert for signs and
for discharge after being hospitalized for an symptoms of:
adrenal crisis. Which statements by the client 1. calcium and phosphorus abnormalities
would indicate that client teaching has been 2. chloride and magnesium abnormalities
effective? 3. sodium and chloride abnormalities
1. "I have to take my steroids for 10 days." 4. sodium and potassium abnormalities
2. "I need to weigh myself daily to be sure I
don't eat too many calories." 10. A client with Cushing's syndrome is
3. "I need to call my doctor to discuss my admitted to the medical-surgical unit. During
steroid needs before I have dental work." the admission assessment, the nurse notes that
4. "I will call the doctor if I suddenly feel the client is agitated and irritable, has poor
profoundly weak or dizzy." memory, reports loss of appetite, and appears
5. "If I feel like I have the flu, I'll carry on as disheveled. These findings are consistent with
usual because this is an expected response." which problem?
6. "I need to obtain and wear a Medic Alert 1. depression
bracelet." 2. neuropathy
3. hypoglycemia
6. When teaching a client with Cushing's 4. Hyperthyroidism
syndrome about dietary changes, the nurse
should instruct the client to increase intake of: 11. Which nursing diagnosis is most appropriate
1. fresh fruits for a client with Addison's disease?
2. dairy products 1. Risk for infection
3. processed meats 2. Excessive fluid volume
4. cereals and grains 3. Urinary retention
4. Hypothermia
7. In a 28-year-old female client who is being
successfully treated for Cushing's syndrome, the 12. A client with a history of Addison's disease
nurse would expect a decline in: and flulike symptoms accompanied by nausea
1. serum glucose level and vomiting over the past week is brought to
2. hair loss the facility. When he awoke this morning, his
3. bone mineralization wife noticed that he acted confused and was
4. menstrual flow extremely weak. The client's blood pressure is
90/58 mm Hg, his pulse is 116 beats/minute,
and his temperature is 101° F (38.3° C). A
diagnosis of acute adrenal insufficiency is made. 3. "I'll take two-thirds of the dose when I wake
What would the nurse expect to administer by up and one-third in the late afternoon."
I.V. infusion? 4. "I'll take the entire dose at bedtime."
1. Insulin
2. Hydrocortisone 17. The nurse is assessing a client with Cushing's
3. Potassium syndrome. Which observation should the nurse
4. Hypotonic saline report to the physician immediately?
1. pitting edema of the legs
13. The nursing care for the client in addisonian 2. an irregular apical pulse
crisis should include which intervention? 3. dry mucous membranes
1. Encouraging independence with activities of 4. frequent urination
daily living (ADLs)
2. Allowing ambulation as tolerated
3. Offering extra blankets and raising the heat in 18. A 35-year-old female client who complains
the room to keep the client warm of weight gain, facial hair, absent menstruation,
4. Placing the client in a private room frequent bruising, and acne is diagnosed with
Cushing's syndrome. Cushing's syndrome is
14. Before discharge, what should a client with most likely caused by:
Addison's disease be instructed to do when 1. an ectopic corticotropin-secreting tumor
exposed to periods of stress? 2. adrenal carcinoma
1. administer hydrocortisone I.M. 3. a corticotropin-secreting pituitary adenoma
2. Drink 8 oz of fluids. 4. an inborn error of metabolism.
3. Perform capillary blood glucose monitoring
four times daily MUSCULOSKELETAL SYSTEM
4. Continue to take his usual dose of
hydrocortisone. 1. The head of the femur placed into the
acetabulum forms the:
15. For a client in addisonian crisis, it would be A. hip joint
very risky for a nurse to administer: B. shoulder
1. potassium chloride C. elbow
2. normal saline solution D. knee
3. hydrocortisone
4. Fludrocortisone 2.A middle-age client seeks clarification from
the nurse about the difference between a
16. The nurse is teaching a client recovering muscle strain and a muscle sprain. The nurse
from addisonian crisis about the need to take explains that: (Select all that apply.)
fludrocortisone acetate and hydrocortisone at 1. A strain includes the partial tear or
home. Which statement by the client indicates overstretching of a muscle or tendon
an understanding of the instructions? 2. A sprain includes a tear or overstretching of a
1. "I'll take my hydrocortisone in the late ligament
afternoon, before dinner." 3. A strain is medical terminology for a fatigued
2. "I'll take all of my hydrocortisone in the muscle
morning, right after I wake up." 4. A sprain is medical terminology for a
ruptured tendon
5. A strain is a term for inflammation and B. wear an elastic compression bandage
weakness in skeletal muscles continuously.
C. use pillows to keep the arm elevated above
A. 1 and 2 the heart.
B. 3 and 4 D. gently exercise the joint to prevent muscle
C. 1 and 5 shortening.
D. 2 and 4
7. A 22-year-old patient started an exercise
[Link] nurse should ask the client to only flex regimen 2 months ago that includes running 3
and extend the knees because they have what to 4 miles a day. The patient tells the nurse, "I
type of joints? enjoy my daily runs, but now I have shin
A. Hinge splints." Which response by the nurse is
B. Saddle appropriate?
C. Pivot A. "You may be increasing your running time
D. Condyloid too quickly and need to cut back a little bit."
B. "You need to have x-rays of your lower legs
[Link] performing a musculoskeletal to be sure you do not have stress fractures."
assessment, the nurse must remember to: C. "You should expect some leg pain while
A. Use as many client position changes as running."
possible D. "You should try speed-walking rather than
B. Work distal to proximal running."
C. Attempt to move a joint about 5 degrees
farther when pain is elicited [Link] a motor-vehicle accident, a patient
D. Demonstrates the movements arrives in the emergency department with
massive right lower-leg swelling. Which action
5.A patient arrives in the emergency will the nurse take first?
department with ankle swelling and severe A. Elevate the leg on pillows.
pain after twisting the ankle playing soccer. All B. Apply a compression bandage.
of the following orders are written by the health C. Place ice packs on the lower leg.
care provider. Which one will the nurse act on D. Check leg pulses and sensation.
first?
A. Administer naproxen (Naprosyn) 500 mg PO. [Link] nurse is assessing the passive range of
B. Wrap the ankle and apply an ice pack. motion of a patient's shoulder. The patient
C. Give acetaminophen with codeine (Tylenol complains of pain during circumduction when
#3). the nurse moves the arm behind the patient.
D. Take the patient to the radiology department Which question should the nurse ask?
for x-rays. A. "Do you ever have trouble making it to the
toilet?"
[Link] x-rays of an injured wrist, the B. "Do you have difficulty putting on a jacket?"
patient is informed that it is badly sprained. In C. "Are you able to feed yourself without
teaching the patient to care for the injury, the difficulty?"
nurse tells the patient to D. "How well are you able to sleep at night?"
A. apply a heating pad to reduce muscle spasms
[Link] assessing the musculoskeletal system, D. Secure the thumb in a plastic bag and place it
the nurse's initial action will usually be to on ice.
A. have the patient move the extremities
against resistance. [Link] Jewish client with peripheral vascular
B. feel for the presence of crepitus during joint disease is scheduled for a left AKA. Which
movement. question is most important for the operating
C. observe the patient's body build and muscle room nurse to ask the client?
configuration. A. "Have you made any special arrangements
D. check active and passive range of motion for for your amputated limb?"
the extremities. B. "What types of food would you like to eat
while you're in the hospital?"
C. "Would you like a rabbi to visit you while you
are in the recovery room?"
[Link] 62-year-old client diagnosed with type 2 D. "Will you start checking your other foot at
diabetes who has a gangrenous right toe is least once a day for cuts?"
being admitted for a below-the-knee
amputation. Which nursing intervention should [Link] client is three (3) hours postoperative
the nurse implement? left AKA. The client tells the nurse, "My left foot
A. Assess the client's nutritional status. is killing me. Please do something." Which
B. Refer the client to an occupational therapist. intervention should the nurse implement?
C. Determine if the client is allergic to IVP dye. A. Explain to the client his left leg has been
D. Start a 22-gauge Angiocath in the right arm. amputated.
B. Medicate the client with a narcotic analgesic
[Link] male nurse is helping his friend cut wood immediately.
with an electric saw. His friend cuts two fingers C. Instruct the client on how to perform
off his left hand with the saw. Which action biofeedback exercises.
should the nurse implement first? D. Place the client's residual limb in the
A. Wrap the left hand with towels and apply dependent position.
pressure.
B. Instruct the friend to hold his hand above his [Link] nurse is caring for a client with a right
head. below-the-knee amputation. There is a large
C. Apply pressure to the radial artery of the left amount of bright red blood on the client's
hand. residual limb dressing. Which intervention
D. Go into the friend's house and call 161. should the nurse implement first?
A. Notify the client's surgeon immediately.
13.A person's right thumb was accidentally B. Assess the client's blood pressure and pulse.
severed with an axe. The amputated right C. Reinforce the dressing with additional
thumb was recovered. Which action by the dressing.
nurse preserves the thumb so it could possibly D. Check the client's last hemoglobin and
be reattached in surgery? hematocrit level.
A. Place the right thumb directly on some ice.
B. Put the right thumb in a glass of warm water. [Link] 27-year-old client has a right above-the-
C. Wrap the thumb in a clean piece of material. elbow amputation secondary to a boating
accident. Which statement to the rehabilitation
nurse indicates the client has accepted the the nurse include about ways to prevent
amputation? fractures?
A. "I am going to sue the guy who hit my boat." A. Tack down scatter rugs in the home.
B. "The therapist is going to help me get B. Most falls happen outside the home.
retrained for another job." C. Buy shoes that provide good support and are
C. "I decided not to get a prosthesis. I don't comfortable to wear.
think I need it." D. Range-of-motion exercises should be taught
D. "My wife is so worried about me and I wish by a physical therapist.
she weren't."
22.A patient is seen at the urgent care center
[Link] nurse explains that which diagnostic test after falling on the right arm and shoulder. It
best demonstrates musculoskeletal will be most important for the nurse to
and soft tissue damage? determine
A. Standard x-rays A. whether there is bruising at the shoulder
B. Electromyography (EMG) area.
C. Computed tomography (CT) B. whether the right arm is shorter than the left.
D. Magnetic resonance imaging (MRI) C. the amount of pain the patient is
experiencing.
[Link] patient's ankle heals, and his cast is D. how much range of motion (ROM) is present.
removed. What education will the nurse
include when teaching the patient to care for 23.A checkout clerk in a grocery store has
his ankle after the cast is removed? muscle and tendon tears that have become
A. "Scrub your lower leg and ankle to remove inflamed, causing pain and weakness in the left
dead, scaly skin." hand and elbow. The nurse identifies these
B. Wear a support stocking to prevent lower symptoms as related to
extremity swelling." A. muscle spasms.
C. "Keep your ankle in a low position to B. meniscus injury.
facilitate perfusion to the healed bone." C. repetitive strain injury.
D. "Exercise vigorously at least 3 times a day as D. carpal tunnel syndrome.
directed by the physical
therapist." 24.A coworker twisted her ankle going down
the stairs. It is swollen and is painful when she
[Link] patient is brought to the emergency bears weight on it. Which intervention would be
department after a car accident and has a the least helpful for healing this sprain?
femur fracture. What nursing intervention A. Avoiding bearing weight on her ankle.
should the nurse implement to prevent a fat B. Wrapping her ankle with an elastic bandage.
embolism in this patient? C. Applying heat to her ankle for 20 minutes at a
A. Administer enoxaparin (Lovenox). time.
B. Provide range-of-motion exercises. D. Elevating her ankle on a pillow while she is
C. Apply sequential compression boots. lying down.
D. Immobilize the fracture preoperatively.
[Link] purpose of which of the following
[Link] teaching seniors at a community devices is to prevent flexion of an affected
recreation center, which information will joint?
1. Cast C. The acetabular cup and head of the tibia and
2. Immobilizer fibula.
3. Splint D. The head and neck of the femur and the
4. Elastic Bandages acetabular cup.
5. Traction
[Link] Pillow [Link] are caring for a patient with a fresh total
hip replacement. Which statement would
A. 1, 2, 3 indicate that your patient needs more teaching?
B. 4, 5, 6 A. "I will sleep with the abductor pillow
C. 2, 4, 6 between my legs every night for several
D. 1, 3, 5 months."
B. "I can cross my legs when I am sitting in a
26.A patient comes into the clinic with his arm chair, as long as my feet are elevated on a
in a cast. You notice a small amount of thick, footstool."
yellow drainage coming from under the cast, C. "I need to use an extension gripper to pick up
and it has an unpleasant odor. There is no anything I drop."
drainage staining the cast, and no open areas of D. "I will sit in the recliner with the back slightly
skin are visible at the edge of the cast. Which reclined when I am out of bed."
question is most appropriate to ask this
patient? [Link] falling at home, a patient is admitted to
A. "Have you inserted anything under the cast the emergency department, where x-rays
to scratch your arm?" confirm the presence of an extracapsular
B. "Have you had an upper respiratory infection fracture of the femur. When assessing the
recently?" patient, the nurse would expect to find
C. "Do you have a skin rash anywhere on your A. bruising of the left hip and thigh.
body?" B. numbness in the left leg and hip.
D. "Is the edge of the cast irritating your skin?" C. outward pointing toes on the left leg.
D. weak or non palpable left leg pulses.
27.A patient is in skeletal traction for a
comminuted fracture of the tibia. While giving [Link] getting a patient from the bed into the
pin care, you notice a small amount of serous chair for the first time since having an ORIF of a
drainage around each pin site. hip fracture, the nurse should
Which observation is most accurate? A. use a mechanical lift to transfer the patient
A. The drainage is a symptom of skin infection. from the bed to the chair.
B. This finding is normal for skeletal traction. B. assist the patient to use a walker with partial
C. This is an indication of pin dislocation. weight bearing to assist in transfer to the chair.
D. The drainage is an indication of a bone C. have the patient use crutches with a swing-
infection. through gait to transfer.
[Link] surfaces are replaced when a patient D. ask a nursing assistant to help the patient to
has a total hip replacement? stand at the bedside and pivot to
A. The articular surfaces of the femur and the the chair.
tibia.
B. The posterior surface of the patella and the [Link] the first postoperative day, a patient with
tibia. a below-the-knee amputation complains of pain
in the amputated limb. An appropriate action by D. "I will have someone else put on my shoes
the nurse is to and socks."
A. administer prescribed opioids to relieve the
pain. 36.A patient with severe osteoarthritis of the
B. explain the reasons for phantom limb pain. left knee has undergone left-knee arthroplasty
C. loosen the compression bandage to decrease with replacement of the total knee joint with a
incisional pressure. plastic prosthesis. Postoperatively, the nurse
D. remind the patient that this phantom pain expects care of the leg to include
will diminish over time. A. bed rest for 3 days with the left leg
immobilized in an extended position.
33.A patient undergoes a right below-the-knee B. use of a compression bandage to hold the left
amputation with an immediate prosthetic knee in a flexed position.
fitting. When the patient is returned to the C. progressive leg exercises to obtain 90-degree
nursing unit, the nurse should flexion.
A. Check the surgical site for hemorrhage. D. early ambulation with full weight bearing on
B. take the patient's vital signs frequently. the left leg.
C. keep the residual leg elevated on a pillow.
D. place the patient in a prone position. [Link] nurse observes a patient doing all these
activities after having a hip-replacement
[Link] nurse provides discharge instructions to surgery. Which patient action requires that the
a patient with an above-the-knee amputation nurse intervene immediately?
who will be fitted with a prosthesis when A. The patient sits straight up on the edge of the
healing is complete and the residual limb is well bed.
molded. The nurse determines that teaching B. The patient leans over to pull shoes and socks
has been effective when the patient says, on.
A. "I should change the limb sock when it C. The patient bends over the sink while
becomes soiled or stretched out." brushing his teeth.
B. "I should use lotion on the stump to prevent D. The patient uses crutches with a swing-to
drying and cracking of the skin." gait.
C. "I should elevate my residual limb on a pillow
2 or 3 times a day." 38.A patient is seen at the urgent care center
D. "I should lay on my abdomen for 30 minutes following a blunt injury to the left knee. The
3 or 4 times a day." knee is grossly swollen and very painful, but the
skin is intact. During an arthrocentesis on the
35.A patient is to be discharged from the patient's knee, the nurse would expect the
hospital 4 days after undergoing a total hip aspirated fluid to appear
arthroplasty. A statement by the patient that A. sanguineous.
indicates a need for additional discharge B. purulent and thick.
instructions is C. straw colored.
A. "I should not cross my legs while sitting." D. white, thick, and ropelike.
B. "I can sleep in any position that is
comfortable for me."
C. "I will use a toilet elevator on the toilet seat."