FUNDAMENTALS OF NURSING EXAM CH 60-69 QUIZZES WITH 100% CORRECT ANSWERS(TESTED BY EXPERTS), Exams of Nursing

Download FUNDAMENTALS OF NURSING EXAM CH 60-69 QUIZZES WITH 100% CORRECT ANSWERS(TESTED BY EXPERTS) and more Exams Nursing in PDF only on Docsity! FUNDAMENTALS OF NURSING EXAM CH 60-69 QUIZZES WITH 100% CORRECT ANSWERS(TESTED BY EXPERTS) 2023-2024 A GRADED 1. The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD? a. A client with a history of polycystic kidney disease b. A client with diabetes mellitus and poorly controlled hypertension c. A client who is morbidly obese with a history of vascular disorders d. A client with severe chronic obstructive pulmonary disease Rationale: Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents may cause ESKD. A client with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the client with diabetes and hypertension is likely at highest risk for ESKD. 2. A client is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what issue? a. Hydronephrosis b. Nephritic syndrome c. Pyelonephritis d. Nephrotoxicity Rationale: If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high- pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. This problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity results from chemical causes. 3. An adult client has been hospitalized with pyelonephritis. The nurse's review of the client's intake and output records reveals that the client has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? a. Supplement the client's fluid intake with a high-calorie diet. b. Emphasize the need to limit intake to 2 L of fluid daily. c. Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. d. Encourage the client to continue this pattern of fluid intake. Rationale: Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. Consequently, there is no need to supplement this fluid intake with additional calories or sodium. 2 4. A medical–surgical nurse is teaching a client about the health implications of the client’s recently diagnosed type 2 diabetes. The nurse should teach the client to be proactive with glycemic control to reduce the risk of what health problem? a. Urinary tract infections b. Renal failure c. Pneumonia d. Inflammatory bowel disease Rationale: One chronic disease can lead to the development of other chronic conditions. Diabetes, for example, can eventually lead to neurologic and vascular changes that may result in visual, cardiac, and kidney disease and erectile dysfunction. Diabetes is not directly linked to urinary tract infections, pneumonia, or inflammatory bowel disease. 5. A 76-year-old client is in the emergency department with reports of nausea, dyspnea, and shoulder pain. The spouse stated the client woke up confused, slightly unsteady, and pale. Which problem or condition is most likely occurring? a. Myocardial ischemia b. Urinary tract infection (UTI) c. Lung cancer d. Chronic obstructive pulmonary disease (COPD) Rationale: Older adults may have atypical pain or burning that may be in the upper body rather than substernal. Clients may report vague symptoms such as nausea, vomiting, syncope, mental status changes, and dyspnea. A UTI may present with mental status changes, but additional signs and symptoms include frequent, urgent, and/or painful urination. Lung cancer and COPD both usually present with more specific respiratory changes, such as wheezing and persistent coughing. 6. A 62-year-old woman started experiencing urinary incontinence six months ago and now wears disposable incontinent panties. The client does not drink any fluids after 5 pm and considers this problem part of aging. What priority modifications and advice should be given to this client? a. “While urinary incontinence is part of the aging process, you should still see your health care provider (HCP) about this condition.” b. “You probably have a urinary tract infection and should start drinking cranberry juice.” c. “You could purchase pads to place into washable panties. This would decrease costs and feel less like a diaper.” d. “Urinary incontinence is not part of the aging process. You should see your HCP and increase your water intake.” Rationale: Urinary incontinence affects more women than men under the age of 80. It is not a normal condition due to aging. While embarrassing, the focus should not be on living with it by wearing disposable panties but getting evaluated by an HCP. Adequate consumption of fluids decreases the likelihood of bladder infection. 2 13. A client with difficulty voiding and elevated BUN and creatinine values has been referred by the health care provider for further evaluation. The nurse should anticipate the use of what initial diagnostic test? a. Portable bladder ultrasound b. X-ray c. Computed tomography (CT) d. Nuclear scan Rationale: Portable bladder ultrasound is a method of detecting urinary retention. These devices provide a three-dimensional image of the bladder and should be used after voiding to detect urine retention. Researchers have reported a decrease in urinary tract infections and a shorter hospital stay when this device is used. A portable bladder ultrasound can be done quickly and frequently at the bedside by the nurse to detect urinary retention. There is no ionizing radiation exposure with a portable ultrasound. X- ray, CT, and nuclear scans all use a certain amount of ionizing radiation. 14. A client with recurrent urinary tract infections has just undergone a cystoscopy and reports slight hematuria during the first void after the procedure. What is the nurse's most appropriate action? a. Administer a STAT dose of vitamin K, as prescribed. b. Reassure the client that this is not unexpected and then monitor the client for further bleeding. c. Promptly inform the health care provider of this assessment finding. d. Position the client supine and insert a Foley catheter, as prescribed. Rationale: Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected after cystoscopy. The nurse should explain this to the client and ensure that the bleeding resolves. No clear need exists to report this finding and it does not warrant insertion of a Foley catheter or vitamin K administration. 15. A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. a. Petechiae b. Pain c. Gastrointestinal symptoms d. Changes in voiding e. Jaundice Rationale: Dysfunction of the kidney can produce a complex array of symptoms throughout the body. Pain, changes in voiding, and gastrointestinal symptoms are particularly suggestive of urinary tract disease. Petechiae is not associated with genitourinary health problems. Jaundice is not a sign of urinary tract infection in an adult; it is seen typically in newborns. 2 16. The nurse is reviewing the electronic health record of a client with a history of incontinence. The nurse reads that the health care provider assessed the client's deep tendon reflexes. What condition of the urinary/renal system does this assessment address? a. Renal calculi b. Bladder dysfunction c. Benign prostatic hyperplasia (BPH) d. Recurrent urinary tract infections (UTIs) Rationale: The deep tendon reflexes of the knee are examined for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction because the sacral area, which innervates the lower extremities, is in the same peripheral nerve area responsible for urinary continence. Neurologic function does not directly influence the course of renal calculi, BPH or UTIs. 17. The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury (AKI)? a. An inability to initiate voiding for 2 days. b. The urine is cloudy and has visible sediment with a foul odor. c. Average urine output has been 10 mL/hr for several hours. d. Client reports left-sided flank pain. Rationale: Oliguria (<400 mL/day of urine or 0.5 mL/kg an hour over 6 hours) is the most common clinical situation seen in AKI. The client’s inability to void and/or urine hesitancy is typically seen with kidney stones, prostate problems, and/or a urinary tract infection (UTI). Urine that has visible sediment and is cloudy and foul smelling is more suggestive of a UTI. Acute flank pain is sometimes seen in AKI. Generally, flank pain has some connection to a variety of kidney diseases like acute glomerular inflammation and polycystic kidney disease. 18. A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client? a. Bathe daily and keep the perineal region clean. b. Avoid voiding immediately after sexual intercourse. c. Drink liberal amounts of fluids. d. Void at least every 6 to 8 hours. Rationale: The client is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The client should be encouraged to shower rather than bathe. 2 19. The nurse is caring for a client who underwent percutaneous (endourologic) lithotripsy earlier in the day. What instruction should the nurse give the client? a. Limit oral fluid intake for 1 to 2 days. b. Report the presence of fine, sand-like particles through the nephrostomy tube. c. Notify the health care provider about cloudy or foul-smelling urine. d. Report any pink-tinged urine within 24 hours after the procedure. Rationale: The client should report the presence of foul-smelling or cloudy urine since this is suggestive of a urinary tract infection (UTI). Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal due to residual stone products. Hematuria is common after lithotripsy. 20. The nurse is teaching a health class of older adults about urinary tract infections (UTI)s. What characteristic of UTIs should the nurse cite? a. Men over age 65 are equally prone to UTIs as women but are more often asymptomatic. b. The prevalence of UTIs in older men approaches that of women in the same age group. c. Men of all ages are less prone to UTIs, but typically experience more severe symptoms. d. The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs. Rationale: The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging, resulting in increased incidence. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs. 21. A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population? a. Administer prophylactic antibiotics as prescribed. b. Limit the use of indwelling urinary catheters. c. Encourage frequent mobility and repositioning. d. Toilet residents who are immobile on a scheduled basis. Rationale: When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adult's risk of developing a UTI. Regular toileting promotes continence but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally given. Mobility does not have a direct effect on UTI risk. 22. A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? a. Impaired physical mobility related to presence of an indwelling urinary catheter b. Risk for infection related to presence of an indwelling urinary catheter c. Deficient knowledge regarding indwelling urinary catheter care d. Disturbed body image related to urinary catheterization Rationale: Fifty percent of all hospital-acquired infections are urinary tract infections (UTI), with a large number being associated with indwelling urinary catheters. This adverse infection is frequently referred 2 b. Renal failure c. Pneumonia d. Inflammatory bowel disease ANS: Rationale: One chronic disease can lead to the development of other chronic conditions. Diabetes, for example, can eventually lead to neurologic and vascular changes that may result in visual, cardiac, and kidney disease and erectile dysfunction. Diabetes is not directly linked to urinary tract infections, pneumonia, or inflammatory bowel disease. 29. A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't sterile water be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? a. Never, because it rapidly enters red blood cells, causing them to rupture. b. When the client is severely dehydrated, resulting in neurologic signs and symptoms c. When the client is in excess of calcium and/or magnesium ions d. When a client's fluid volume deficit is due to acute or chronic kidney disease Rationale: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture. 30. A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing which health problem? a. Chronic kidney disease b. Right ventricular hypertrophy c. Glaucoma d. Anemia Rationale: When uncontrolled hypertension is prolonged, it can result in chronic kidney disease, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension. 31. A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the client's chronic kidney disease is at what stage? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 Rationale: Stages of chronic kidney disease are based on the GFR. Stage 3 is defined by a GFR in the range of 30 to 59 mL/min/1.73 m2. This is considered a moderate decrease in GFR. 32. A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly, and that the client's abdomen is increasing in girth. What is the nurse's most appropriate action? 2 a. Advance the catheter 2 to 4 cm further into the peritoneal cavity. b. Reposition the client to facilitate drainage. c. Aspirate from the catheter using a 60-mL syringe. d. Infuse 50 mL of additional dialysate. Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate. 33. A nurse on a busy medical unit provides care for many clients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which client? a. A client whose diagnosis of chronic kidney disease requires a fluid restriction b. A client who has Alzheimer disease and who is acutely agitated c. A client who is on bed rest following a recent episode of venous thromboembolism d. A client who has decreased mobility following a trans metatarsal amputation Rationale: Clients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated. Recent VTE, amputation, and fluid restriction do not directly create a risk for injury or trauma associated with indwelling catheter use. 34. A client comes to the clinic reporting a tender, inflamed vulva. Testing does not reveal the presence of any known causative microorganism. What aspect of this client's current health status may account for the client's symptoms of Vulvitis? a. The client is morbidly obese. b. The client has type 1 diabetes. c. The client has chronic kidney disease. d. The client's mother had similar problems in mid-adulthood. Rationale: Vulvitis, an inflammation of the vulva, may occur as a result of other disorders, such as diabetes, dermatologic problems, or poor hygiene. Obesity, kidney disease, and family history are less likely causes than diabetes. 35. The nurse is leading a workshop on sexual health for men. The nurse should describe what organic causes of erectile dysfunction? Select all that apply. a. Diabetes b. Testosterone deficiency c. Anxiety d. Depression e. Parkinsonism Rationale: Organic causes of ED include cardiovascular disease, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic kidney disease, genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin disease, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury, multiple sclerosis), trauma to the 2 pelvic or genital area, alcohol, smoking, medications, and drug abuse. Anxiety and depression are considered to be psychogenic causes. 36. Which client(s) should use caution when taking spironolactone as an androgen- reducing medication? Select all that apply. a. Client with diabetes b. Client with hypokalemia c. Client with adrenal insufficiency d. Client with chronic kidney disease e. Client with depression Rationale: Spironolactone is a diuretic that also directly inhibits testosterone secretion and androgen binding to the androgen receptor. It should be used with caution with clients who have diabetes, hyperkalemia, adrenal insufficiency, and chronic kidney disease. Hypokalemia and depression will not impact the administration of this medication. 37. The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? a. Complete bed rest b. Bed rest with bathroom privileges c. Out of bed (OOB) to the chair twice a day d. Ambulation and activity as tolerated Rationale: Mobility, through walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Bed rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the client to getting out of bed only a few times a day also increases calcium excretion and the associated risks. 38. The nurse is caring for a client who has been diagnosed with renal calculi. Prompt management of renal calculi is most important when the stone is located where? a. In the ureteropelvic junction b. In the ureteral segment near the sacroiliac junction c. In the ureterovesical junction d. In the urethra Rationale: The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovesical junction. These three areas of the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of the ureteropelvic junction is most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The urethra is not part of the ureter. 39. A client admitted to the medical unit with impaired renal function reports severe, stabbing pain in the flank and lower abdomen. The client is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location? a. Meatus 2 46. A client with diabetic nephropathy has end-stage renal disease and is starting dialysis. What should the nurse teach the client about hemodialysis? a. "Hemodialysis is a treatment option that is usually required three times a week." b. "Hemodialysis is a program that will require you to commit to daily treatment." c. "This will require you to have surgery and a catheter will need to be inserted into your abdomen. d. " D. "Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again." Rationale: Hemodialysis is the most commonly used method of dialysis. Clients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatment usually occurs three times a week for at least 3 to 4 hours per treatment. Peritoneal dialysis, not hemodialysis, requires placement of a catheter inserted into the abdomen. 47. A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? a. Inform the health care provider and assess the client for signs of infection. b. Flush the peritoneal catheter with normal saline. c. Remove the catheter promptly and have the catheter tip cultured. d. Administer a bolus of IV normal saline as prescribed. Rationale: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection. 48. The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? a. The client's bladder is not completely empty. b. The client has kidney enlargement. c. The client has a ureteral obstruction. d. The client has a fluid volume deficit. Rationale: Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying. Enlargement of the kidneys can be attributed to numerous conditions such as polycystic kidney disease or hydronephrosis and is not related to bladder fullness. Dehydration and ureteral obstruction are not related to bladder fullness; in fact, these conditions result in decreased flow of urine to the bladder. 49. The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury (AKI)? a. An inability to initiate voiding for 2 days. 2 b. The urine is cloudy and has visible sediment with a foul odor. c. Average urine output has been 10 mL/hr for several hours. d. Client reports left-sided flank pain. Rationale: Oliguria (<400 mL/day of urine or 0.5 mL/kg an hour over 6 hours) is the most common clinical situation seen in AKI. The client’s inability to void and/or urine hesitancy is typically seen with kidney stones, prostate problems, and/or a urinary tract infection (UTI). Urine that has visible sediment and is cloudy and foul smelling is more suggestive of a UTI. Acute flank pain is sometimes seen in AKI. Generally, flank pain has some connection to a variety of kidney diseases like acute glomerular inflammation and polycystic kidney disease. 50. A client on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurse's care of this client? a. The disease is self-limiting, and cysts usually resolve spontaneously in the fifth or sixth decade of life. b. The client's disease is incurable, and the nurse's interventions will be supportive. c. The client will eventually require surgical removal of his or her renal cysts. d. The client is likely to respond favorably to lithotripsy treatment of the cysts. Rationale: Nursing actions focus on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy. 51. The nurse performing the health interview of a client with a new onset of periorbital edema has completed a genogram, noting the health history of the client's siblings, parents, and grandparents. This assessment addresses the client's risk of what kidney disorder? a. Nephritic syndrome b. Acute glomerulonephritis c. Nephrotic syndrome d. Polycystic kidney disease (PKD) Rationale: PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders. 52. The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? a. The client's bladder is not completely empty. b. The client has kidney enlargement. c. The client has a ureteral obstruction. d. The client has a fluid volume deficit. Rationale: Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying. Enlargement of the kidneys can be attributed to numerous conditions such as polycystic kidney disease or hydronephrosis and is not related to bladder fullness. Dehydration and ureteral 2 obstruction are not related to bladder fullness; in fact, these conditions result in decreased flow of urine to the bladder. 53. The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury (AKI)? a. An inability to initiate voiding for 2 days. b. The urine is cloudy and has visible sediment with a foul odor. c. Average urine output has been 10 mL/hr for several hours. d. Client reports left-sided flank pain. Rationale: Oliguria (<400 mL/day of urine or 0.5 mL/kg an hour over 6 hours) is the most common clinical situation seen in AKI. The client’s inability to void and/or urine hesitancy is typically seen with kidney stones, prostate problems, and/or a urinary tract infection (UTI). Urine that has visible sediment and is cloudy and foul smelling is more suggestive of a UTI. Acute flank pain is sometimes seen in AKI. Generally, flank pain has some connection to a variety of kidney diseases like acute glomerular inflammation and polycystic kidney disease. 54. The nurse performing the health interview of a client with a new onset of periorbital edema has completed a genogram, noting the health history of the client's siblings, parents, and grandparents. This assessment addresses the client's risk of what kidney disorder? a. Nephritic syndrome b. Acute glomerulonephritis c. Nephrotic syndrome d. Polycystic kidney disease (PKD) Rationale: PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders. 55. The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? a. Hematuria b. Precipitous decrease in serum creatinine levels c. Hypotension unresolved by fluid administration d. Glucosuria Rationale: The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Glucosuria does not normally accompany glomerulonephritis, and hypertension is much more likely than hypotension. 2 63. The nurse is caring for clients in the urology clinic. A new, 73-year-old client presents with reports of urinary incontinence and is prescribed an anticholinergic. Why might this type of medication be an inappropriate choice in the older adult population? a. Gastrointestinal hypermotility can be an adverse effect of this medication. b. Detrusor instability can be an adverse effect of this medication. c. Confusion can be an adverse effect of this medication. d. Increased symptoms of urge incontinence can be an adverse effect of this medication. Rationale: Although medications such as anticholinergics may decrease some of the symptoms of urge incontinence (detrusor instability), the adverse effects of these medications (dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate choices for older adults. 64. The nurse is caring for a 91-year-old client who reports urge incontinence and sometimes falling when trying to get to the bathroom at home. The nurse identifies the nursing diagnosis of Risk for Falls related to impaired mobility and urinary incontinence. This client's risk for falls is considered to be which of the following? a. The result of impaired cognitive functioning b. The accumulation of environmental hazards c. A geriatric syndrome d. An age-related health deficit Rationale: A number of problems commonly experienced by older adults are becoming recognized as geriatric syndromes. These conditions do not fit into discrete disease categories. Examples include frailty, delirium, falls, urinary incontinence, and pressure ulcers. Impaired cognitive functioning, environmental hazards in the home, and an age-related health deficit may all play a part in the episodes in this client's life that led to falls, but they are not diagnoses and are, therefore, incorrect. 65. The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics? a. Avoid drinking fluids for 2 hours after taking the diuretic. b. Take the diuretic in the morning to avoid interfering with sleep. c. Avoid taking the medication within 2 hours consuming dairy products. d. Take the diuretic only on days when experiencing shortness of breath. Rationale: Oral diuretics should be given early in the morning so that diuresis does not interfere with the client's nighttime rest. Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated. 66. A client with myelodysplastic syndrome (MDS) is being treated on a medical unit. Which priority finding should prompt the nurse to contact the client's primary care provider? a. Reports of a frontal lobe headache b. An episode of urinary incontinence c. An oral temperature of 37.5°C (99.5°F) 2 d. An oxygen saturation (SpO2) of 91% on room air Rationale: Because the client with MDS is at a high risk for infection, any early signs of infection must be reported promptly. The nurse should address each of the listed assessment findings, but none is as direct a threat to the client's immediate health as an infection. 67. A nurse is performing an admission assessment on a client with stage 3 human immunodeficiency virus (HIV). After assessing the client's gastrointestinal system and analyzing the data, which nursing diagnosis is most likely to be the priority? a. Acute abdominal pain b. Diarrhea c. Bowel incontinence d. Constipation ANS: B Rationale: Diarrhea is a problem in many clients with HIV and acquired immunodeficiency syndrome. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply. 68. A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? a. Risk for activity intolerance related to the presence of a subclavian catheter b. Risk for infection related to the presence of a subclavian catheter c. Risk for functional urinary incontinence related to the presence of a subclavian catheter d. Risk for sleep deprivation related to the presence of a subclavian catheter Rationale: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The client will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these. 69. A geriatric nurse is performing an assessment of body systems on an older adult client. The nurse should be aware of what age-related change affecting the renal and urinary systems? a. Increased ability to concentrate urine b. Increased bladder capacity c. Urinary incontinence d. Decreased glomerular filtration rate Rationale: Many age-related changes in the renal and urinary systems should be taken into consideration when taking a health history of an older adult. One change includes a decreased glomerular surface area resulting in a decreased glomerular filtration rate. Other changes include the decreased ability to concentrate urine and a decreased bladder capacity. It also should be understood that urinary incontinence is not a normal age-related change, but is common in older adults, especially in women because of the loss of pelvic muscle tone. 2 70. The nurse is reviewing the electronic health record of a client with a history of incontinence. The nurse reads that the health care provider assessed the client's deep tendon reflexes. What condition of the urinary/renal system does this assessment address? a. Renal calculi b. Bladder dysfunction c. Benign prostatic hyperplasia (BPH) d. Recurrent urinary tract infections (UTIs) Rationale: The deep tendon reflexes of the knee are examined for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction because the sacral area, which innervates the lower extremities, is in the same peripheral nerve area responsible for urinary continence. Neurologic function does not directly influence the course of renal calculi, BPH or UTIs. 71. Dipstick testing of an older adult client's urine indicates the presence of protein. Which statement is true of this assessment finding? a. This finding needs to be considered in light of other forms of testing. b. This finding is a risk factor for urinary incontinence. c. This finding is likely the result of an age-related physiologic change. d. This result confirms that the client has diabetes. Rationale: A dipstick examination should be used as a screening test only, because urine concentration, pH, hematuria, and radiocontrast materials all affect the results. Proteinuria is not diagnostic of diabetes, and it is neither an age-related change nor a risk factor for incontinence. 72. A 42-year-old woman comes to the clinic reporting occasional urinary incontinence when sneezing. The clinic nurse should recognize what type of incontinence? a. Stress incontinence b. Reflex incontinence c. Overflow incontinence d. Functional incontinence Rationale: Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure, such as a result of exertion, sneezing, coughing, or changing positions. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors (outside the urinary system) make it difficult or impossible for the client to reach the toilet in time for voiding. 73. The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? a. Provide medication teaching related to pseudoephedrine sulfate. b. Teach the client to perform pelvic floor muscle exercises. c. Prepare the client for an anterior vaginal repair procedure. d. Provide information on periurethral bulking. 2 Rationale: Pelvic floor muscles can promote the resumption of normal urinary function following prostate surgery. Catheterization is normally unnecessary, and it carries numerous risks of adverse effects. Increasing or decreasing physical activity is unlikely to influence urinary function. 80. A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? a. Urinary retention b. Bladder spasms c. Urge incontinence d. Bladder contract Rationale: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder. 81. The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image. a. Confusion b. Uncertainty c. Depression d. Disassociation Rationale: Depression is a common and genuine problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients. 82. The nurse is caring for an adult client who has just received a diagnosis of prostate cancer. The client states, “I will never be able to cope with this situation.” How should the nurse best understand the concept of stress when attempting to meet this client's needs? a. It is a physiologic measurement used to deal with change, and the client will physically adapt. b. It is a physiologic or psychological process that the client implements to adapt to change. c. It is an external event or situation that produces change that does not contribute to growth. d. It is a disruptive condition produced by a change that influences the client’s dynamic balance. Rationale: Stress is a disruptive condition produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium. Stressors can be described as psychological, physiologic, or psychosocial. Stress can be an internal or external event and contributes to growth. 2 83. An older adult male client has been diagnosed with prostate cancer. Neither the client nor his family has a history of cancer. What is the most likely genetic reason for his diagnosis? a. Germline mutation b. Single nucleotide polymorphism mutation c. Inherited gene mutation d. Hemoglobin S gene mutation Rationale: Genetic variations occur among all people. Single nucleotide polymorphisms (SNPs) are genetic variations that frequently occur throughout the human genome. Some SNPs do alter gene function and may influence development of cancer, diabetes, and heart disease. Germline or inherited gene mutations are present in the DNA body cells and are passed on in reproductive cells. Hemoglobin S gene mutation is a small gene mutation and a client who has two copies of this mutation has sickle cell disease. 84. During a routine mammogram, a client asks the nurse whether breast cancer causes the most deaths. Which type of cancer is the leading cause of death in the United States? a. Colorectal b. Prostate c. Lung d. Breast Rationale: Lung cancer is the leading cause of cancer-related deaths in the United States, followed by prostate cancer in men and breast cancer in women. Colorectal cancer is the third-leading cause of cancer-related deaths in the United States. Cancer is a common health problem worldwide. 85. A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high- dose radiation (HDR). What safety measure should the nurse include in this client's plan of care? a. Limit the time that visitors spend at the client's bedside. b. Teach the client to perform all aspects of basic care independently. c. Assign male nurses to the client's care whenever possible. d. Situate the client in a shared room with other clients receiving brachytherapy Rationale: To limit radiation exposure, visitors should generally not spend more than 30 minutes with the client. Pregnant nurses or visitors should not be near the client, but there is no reason to limit care to nurses who are male. All necessary care should be provided to the client and a single room should be used. 86. The nurse is assessing a 73-year-old client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the client is most likely in what stage of death and dying? a. Depression b. Denial c. Anger d. Resignation 2 Rationale: Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life. 87. A client has just been diagnosed with prostate cancer and is scheduled for brachytherapy the following week. The client and spouse are unsure of having the procedure because their child is 3 months’ pregnant. What is the most appropriate teaching the nurse should provide to this family? a. The client should not be in contact with the baby after delivery. b. The client's treatment poses no risk to the child or the infant. c. The client's brachytherapy may be contraindicated for safety reasons. d. The client should avoid close contact with the child for 2 months. Rationale: Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. The surgeon uses ultrasound guidance to place about 80 to 100 seeds, and the client returns home after the procedure. Exposure of others to radiation is minimal, but the client should avoid close contact with pregnant women and infants for up to 2 months. 88. A nurse is teaching a 53-year-old man about prostate cancer, given the fact that the client has a family history of the disease. What information should the nurse provide to best facilitate the early identification of prostate cancer? a. Have a digital rectal examination and prostate-specific antigen (PSA) test done as recommended. b. Have a transrectal ultrasound every 5 years. c. Perform monthly testicular self-examinations, especially after age 60. d. Have a complete blood count (CBC), blood urea nitrogen (BUN), and creatinine assessment performed annually. Rationale: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and the PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that are especially relevant when a client has a family history. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound and CBC with BUN and creatinine assessment are usually done after diagnosis to identify the extent of disease and potential metastases. 89. A nurse is providing an educational event to a local men's group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group? a. Native Americans/First Nations b. White c. Black d. Asian Rationale: Black men have the highest considerable risk of prostate cancer. 2 Rationale: Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL (177 mol/L) identify the client as being at considerable risk. Preprocedural hydration the day prior to the test is effective in prevention. The nurse would not monitor the client's electrolytes every hour pre-procedure because this would not change the client’s risk factors. To decrease this risk factor, an intervention is needed. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast. 97. A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? a. Hemodialysis b. Peritoneal dialysis c. Continuous venovenous hemodialysis (CVVHD) d. Plasmapheresis Rationale: CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable client. Peritoneal dialysis is not the best choice, as the client may have sustained abdominal injuries during the accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance. 98. A 76-year-old client with ESKD has been told by the health care provider that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse about feeling unsure about undergoing a kidney transplant. What would be an appropriate response for the nurse to make? a. "The decision is certainly yours to make but be sure not to make a mistake." b. "Kidney transplants in peoples your age is as successful as they are in younger clients." c. "I understand your hesitancy to commit to a transplant surgery. Success is relatively rare." d. "Have you talked this over with your family?" Rationale: Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the older adult. However, the success rate of the surgery is comparable to that for younger clients. The other listed options either belittle the client or give the client misinformation. 99. A client has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? a. Administration of acyclovir b. Hematopoietic stem cell transplantation (HSCT) c. Administration of penicillin d. Hemodialysis 2 Rationale: Anthrax infection is treated with penicillin. Acyclovir is ineffective because anthrax is a bacterium. Dialysis and HSCT are not indicated. 100. A client with diabetic nephropathy has end-stage renal disease and is starting dialysis. What should the nurse teach the client about hemodialysis? a. "Hemodialysis is a treatment option that is usually required three times a week." b. "Hemodialysis is a program that will require you to commit to daily treatment." c. "This will require you to have surgery and a catheter will need to be inserted into your abdomen." d. "Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again." Rationale: Hemodialysis is the most commonly used method of dialysis. Clients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatment usually occurs three times a week for at least 3 to 4 hours per treatment. Peritoneal dialysis, not hemodialysis, requires placement of a catheter inserted into the abdomen. 101. A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? a. Inform the health care provider and assess the client for signs of infection. b. Flush the peritoneal catheter with normal saline. c. Remove the catheter promptly and have the catheter tip cultured. d. Administer a bolus of IV normal saline as prescribed. Rationale: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection. 102. A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? a. Hemodialysis b. Peritoneal dialysis c. Continuous venovenous hemodialysis (CVVHD) d. Plasmapheresis Rationale: CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable client. Peritoneal dialysis is not the best choice, as the client may have sustained abdominal injuries during the 2 accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance. 103. The nurse has identified the nursing diagnosis of "Risk for Infection" in a client who undergoes peritoneal dialysis. What nursing action best addresses this risk? a. Maintain aseptic technique when administering dialysate. b. Wash the skin surrounding the catheter site with soap and water prior to each exchange. c. Add antibiotics to the dialysate as prescribed. d. Administer prophylactic antibiotics by mouth or IV as prescribed. Rationale: Aseptic technique is used to prevent peritonitis and other infectious complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection. 104. A nurse is providing education to the family of a client beginning peritoneal dialysis. The family ask questions concerning catheter placement and stabilization. Which information will the nurse provide about the cuffs? Select all that apply. a. The cuffs are constructed of Dacron polyester material. b. The cuffs will help stabilize the catheter. c. The cuffs prevent the dialysate from leaking. d. The cuffs provide a barrier against microorganisms. e. The cuffs will absorb the dialysate. Rationale: Most catheters used for peritoneal dialysis have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. They do not absorb dialysate. 105. A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly, and that the client's abdomen is increasing in girth. What is the nurse's most appropriate action? a. Advance the catheter 2 to 4 cm further into the peritoneal cavity. b. Reposition the client to facilitate drainage. c. Aspirate from the catheter using a 60-mL syringe. d. Infuse 50 mL of additional dialysate. ANS: B Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate. 106. The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in this client? a. The client will have exaggerated symptoms of rhinosinusitis due to immunosuppression. b. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. c. Chronic rhinosinusitis can damage the transplanted organ. 2 113. The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time? a. Only when needed b. Daily at bedtime c. First thing in the morning d. With each meal Rationale: Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate- binding medications must be given with food to be effective. 114. The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? a. Smoking cessation b. Reduction of alcohol intake c. Maintenance of a diet high in vitamins and nutrients d. Vitamin D supplementation Rationale: People who smoke are significantly more likely to develop bladder cancer than those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer. 115. A client is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The client is quickly learning to self-manage the urinary diversion but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response? a. Report this finding promptly to the primary care provider. b. Obtain a sterile urine sample and send it for culture. c. Obtain a urine sample and check it for ph. d. Reassure the client that this is an expected phenomenon. Rationale: Because mucous membrane is used in forming the conduit, the client may excrete a large amount of mucus mixed with urine. This causes anxiety in many clients. To help relieve this anxiety, the nurse reassures the client that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required. 116. A client has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the client's body image? a. Emphasize that the diversion is an integral part of successful cancer treatment. b. Encourage the client to speak openly and frankly about the diversion. c. Allow the client to initiate the process of providing care for the diversion. 2 d. Provide the client with detailed written materials about the diversion at the time of discharge. Rationale: Allowing the client to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the client is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the client's body image. 117. An adult oncology client has a diagnosis of bladder cancer with metastasis and the client has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? a. The client and family should be viewed as a single unit of care. b. Persistent symptoms of terminal illness should not be treated. c. Each member of the interdisciplinary team should develop an individual plan of care. d. Terminally ill clients should die in the hospital whenever possible. Rationale: Hospice care requires that the client and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care. 118. A medical client's CA 19-9 levels have become available, and they are significantly elevated. How should the nurse best interpret this diagnostic finding? a. The client may have cancer, but other GI disease must be ruled out. b. The client most likely has early-stage colorectal cancer. c. The client has a genetic predisposition to gastric cancer. d. The client has cancer, but the site is unknown. Rationale: CA 19-9 levels are elevated in most clients with advanced pancreatic cancer, but they may also be elevated in other conditions such as colorectal, lung, and gallbladder cancers; gallstones; pancreatitis; cystic fibrosis; and liver disease. A cancer diagnosis cannot be made solely on CA 19-9 results. 119. A 45-year-old client comes into the health clinic for an annual checkup. The client mentions to the nurse that they have noticed dimpling of the right breast that has occurred over the past few months. What assessment would be most appropriate for the nurse to make? a. Inspect the client's breasts for signs of infection. b. Palpate the area for a breast mass. c. Assess the client's knowledge of breast cancer. d. Assure the client that this is likely an age-related change. Rationale: It would be most important for the nurse to palpate the breast to determine the presence of a mass and to refer the client to the primary provider. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance (peau d'orange), a classic sign of advanced breast cancer. The client's knowledge of breast cancer is relevant, but not a time-dependent priority. This finding is not an age-related change. Assessment for signs of malignancy is a priority over infection, which is unlikely to cause these changes. 2 120. The nurse leading an educational session is describing self-examination of the breast. The nurse tells the women's group to raise their arms and inspect their breasts in a mirror. A member of the women's group asks the nurse why raising the arms is necessary. What is the nurse's best response? a. "It helps to spread out the fat that makes up your breast." b. "It allows you to simultaneously assess for pain." c. "It will help to observe for dimpling more closely." d. "This is what breast cancer experts recommend." Rationale: The primary reason for raising the arms is to detect any dimpling. To elicit skin dimpling or retraction that may otherwise go undetected, the examiner instructs the client to raise both arms overhead. Citing expert opinion does not address the client's question. The purpose of raising the arms is not to elicit pain or to redistribute adipose tissue. 121. A client aged 48 years comes to the clinic because they have discovered a lump in the breast. After diagnostic testing, the client receives a diagnosis of breast cancer. The client asks the nurse when the teenage daughters should begin mammography. What is the nurse's best advice? a. Age 28 b. Age 35 c. Age 38 d. Age 48 Rationale: A general guideline is to begin screening 5 to 10 years earlier than the age at which the youngest family member developed breast cancer, but not before age 25 years. In families with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen. Because their mother developed breast cancer at age 48 years, the daughters should begin mammography at age 38 to 43 years. 122. The nurse is caring for a 52-year-old client whose aunt and mother died of breast cancer. The client states, "My doctor and I talked about tamoxifen to help prevent breast cancer. Do you think it will work?" What would be the nurse's best response? a. "Yes, it's known to have a slight protective effect." b. "Yes, but studies also show an increased risk of osteoporosis." c. "You won't need to worry about getting cancer as long as you take tamoxifen." d. "Tamoxifen is known to be a highly effective protective measure." Rationale: Tamoxifen has been shown to be a highly effective chemo preventive agent. However, it cannot reduce the risk of cancer by 100%. It also acts to prevent osteoporosis. 123. During a recent visit to the clinic, a client presents with erythema of the nipple and areola on the right breast. The client states this started several weeks ago, and they were fearful of what would be found. The nurse should promptly refer the client to the primary provider because the client's signs and symptoms are suggestive of what health problem? a. Peau d'orange 2 c. Synchronizing women's routines around BSE with the performance of mammograms d. Women's knowledge of the pathophysiology of breast cancer Rationale: Current practice emphasizes the importance of breast self-awareness, which is a client's attentiveness to the normal appearance and feel of the breasts. BSE does not need to be synchronized with the performance of mammograms. Rapport between the client and the care provider is beneficial but does not necessarily determine the effectiveness of BSE. The client does not need to understand the pathophysiology of breast cancer to perform BSE effectively. 131. A client is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the client is aware of what potential consequence? a. Chronic breast pain b. Unclear mammography results c. Increased risk of breast cancer d. Decreased nipple sensation Rationale: During the preoperative consultation, the client should be informed of a possibility that sensory changes of the nipple (e.g., numbness) may occur. There is no consequent increase in breast cancer risk, and it does not affect future mammography results. Chronic pain is not an expected complication. 132. A client at considerable risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the client asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurse's best response? a. "An incisional biopsy is performed because it's known to be less painful and more accurate than other forms of testing." b. "An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment." c. "An incisional biopsy is performed to assess the potential for recovery from a mastectomy." d. "An incisional biopsy is performed on clients who are younger than the age of 40 and who are otherwise healthy." Rationale: Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies that will aid in determining treatment. Incisional biopsies cannot always remove the whole mass, nor are they always beneficial to the client. The procedure is not chosen because of the potential for pain, the possibility of not recovering from mastectomy, or the client's age. 133. A client has just been diagnosed with breast cancer and the nurse is performing a client interview. In assessing this client's ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask? a. "What is your level of education?" 2 b. "Are you feeling all right these days?” c. "Is there someone you trust to help you make treatment choices?" d. "Are you concerned about receiving this diagnosis?" Rationale: A trusted ally to assist in making treatment choices is beneficial to the client's coping ability. It is condescending and inappropriate to ask if the client is "feeling all right these days" or is concerned about the diagnosis. The client's education level is irrelevant. 134. A client has been diagnosed with stage II breast cancer. The client tells the nurse that the health care provider has recommended breast conservation surgery followed by radiation. The client's husband has done some online research and is asking why his wife does not have a modified radical mastectomy "to be sure all the cancer is gone." The nurse knows that breast conservation surgery was recommended for which reason. a. "Modified radical mastectomies are very hard on a client, both physically and emotionally, and they really aren't necessary anymore." b. "According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial." c. "Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence." d. "According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy." Rationale: Breast conservation along with radiation therapy in stage I and stage II breast cancer results in a survival rate equal to that of modified radical mastectomy. Mastectomies are still necessary in many cases but are not associated with particular risk of recurrence. 135. A man tells the nurse that their father died of prostate cancer and the client is concerned about their own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurse's response? a. A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer. b. HNPCC is a mutation of two genes that causes prostate cancer in men, and it is autosomal dominant. c. Studies have shown that the presence of the TP53 gene strongly influences the incidence of prostate cancer. d. Recent research has demonstrated that prostate cancer is the result of lifestyle factors and that genetics are unrelated. Rationale: A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer. HNPCC is a form of colon cancer. The TP53 gene is associated with breast cancer. 136. A client will undergo a bilateral mastectomy later today and the nurse in surgical admitting has begun the process of client education. What positive outcome of providing the client with information should the nurse expect? 2 a. Increased concentration b. Decreased depression levels c. Sharing personal details d. Building interdependent relationships Rationale: Giving clients information also reduces the emotional response so that they can concentrate and solve problems more effectively. Educating the client does not decrease depression levels or build interpersonal relationships. Educating the client does not mean sharing personal details. 137. A 64-year-old client has returned from surgery after a right mastectomy and is very anxious. The client doesn’t want any medications. What is the best intervention the nurse could employ to manage the client’s anxiety at this time? a. Encourage a brisk walk around the nurse’s station. b. Review post-operational orders and procedural information. c. Use guided imagery and deep breathing exercises. d. Turn off the television and lights and encourage rest. Rationale: Guided imagery is the mindful use of a word, phrase, or visual image for the purpose of distraction from distressing situations. Deep breathing exercises increase the supply of oxygen to the brain and stimulate the parasympathetic nervous system. These can be done easily at the bedside. The client returning from surgery is usually too exhausted, sedated, or in too much pain to go for a brisk walk. While reviewing procedural information before surgery reduces stress, postoperatively it is repeating information that the client already has and may worsen the anxiety. A review of post- operational orders is not the priority and may not be fully understood if anxiety levels are high. Turning off the lights and television may increase anxiety. 138. A woman with a family history of breast cancer received a positive result on a breast tumor marking test and is requesting a bilateral mastectomy. This surgery is an example of which type of oncologic surgery? a. Salvage surgery b. Palliative surgery c. Prophylactic surgery d. Reconstructive surgery Rationale: Prophylactic surgery is used when there is an extensive family history and nonvital tissues are removed. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion. Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect. 139. A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The client has asked if they 2 146. When planning discharge teaching with a client who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the client that they should report what sign or symptom to the health care provider immediately? a. Fatigue b. Temperature greater than 36.9°C (98.5°F) c. Sudden cessation of output from the drainage device d. Gradual decline in output from the drain Rationale: The client should report sudden cessation of output from the drainage device, which could indicate an occlusion. Gradual decline in output is expected. A temperature of 38°C (100.4°F) or greater should also be reported to rule out postoperative infection, but a temperature of 36.9°C (98.5°F) is not problematic. Fatigue is expected during the recovery period. 147. A client at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the client asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurse's best response? a. "An incisional biopsy is performed because it's known to be less painful and more accurate than other forms of testing." b. "An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment." c. "An incisional biopsy is performed to assess the potential for recovery from a mastectomy." d. "An incisional biopsy is performed on clients who are younger than the age of 40 and who are otherwise healthy." Rationale: Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies that will aid in determining treatment. Incisional biopsies cannot always remove the whole mass, nor are they always beneficial to the client. The procedure is not chosen because of the potential for pain, the possibility of not recovering from mastectomy, or the client's age. 148. A nurse has assessed that a client is not yet willing to view the mastectomy site. How should the nurse best assist the client in developing a positive body image? a. Ask the client to describe the current appearance of the breast. b. Help the client to understand that many women have gone through the same unpleasant experience. c. Explain to the client that their body image does not have to depend on their physical appearance. d. Provide the client with encouragement in an empathic and thoughtful manner. Rationale: Gentle encouragement can help client progress toward accepting the change in appearance. The nurse should not downplay the significance of physical appearance. Explaining that others have had similar experiences may or may not benefit the client. Asking the client to describe the appearance of the breast is likely to exacerbate the client's reluctance to do so. 2 149. A client has had a total mastectomy with immediate reconstruction. The client asks the nurse when they can take a shower. What should the nurse respond? a. "Not until the drain is removed" b. "On the second postoperative day" c. "Now, if you wash gently with soap and water" d. "Seven days after your surgery" ANS Rationale: If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed. 150. A client has been discharged home after a total mastectomy without reconstruction. The client lives alone and has a home health referral. When the home care nurse performs the first scheduled visit on this client, what should the nurse assess? Select all that apply. a. Adherence to the exercise plan b. Overall psychological functioning c. Integrity of surgical drains d. Understanding of cancer e. Use of the breast prosthesis Rationale: Clients who have difficulty managing their postoperative care at home may benefit from a home health care referral. The home care nurse assesses the client's incision and surgical drain(s), adequacy of pain management, adherence to the exercise plan, and overall physical and psychological functioning. It is unnecessary to assess the client's understanding of cancer at this stage of recovery. Prostheses may be considered later in the recovery process. 151. A client has been diagnosed with stage II breast cancer. The client tells the nurse that the health care provider has recommended breast conservation surgery followed by radiation. The client's husband has done some online research and is asking why his wife does not have a modified radical mastectomy "to be sure all the cancer is gone." The nurse knows that breast conservation surgery was recommended for which reason. a. "Modified radical mastectomies are very hard on a client, both physically and emotionally, and they really aren't necessary anymore." b. "According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial." c. "Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence." d. "According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy." Rationale: Breast conservation along with radiation therapy in stage I and stage II breast cancer results in a survival rate equal to that of modified radical mastectomy. Mastectomies are still necessary in many cases but are not associated with particular risk of recurrence. 152. Which client statement indicates that additional teaching is required regarding testosterone therapy? 2 a. “My breast size will decrease with the testosterone therapy.” b. “My voice will become deeper with testosterone therapy.” c. “My subcutaneous fat stores will start to decrease.” d. “My menses should stop while I am on testosterone therapy.” Rationale: The administration of testosterone therapy will not decrease breast size. Transgender clients who wish to have a flat chest may have to undergo a mastectomy. The client statements noting that the voice will become deeper, that fat stores will decrease, and that menses will stop are correct. 153. A home health nurse is making a visit to a new client who is receiving home care following a mastectomy. During the visit, the client's husband arrives home in an intoxicated state and speaks to both the nurse and the client in an abusive manner. What is the nurse's best response? a. Ignore the husband and focus on the client. b. Return to the agency and notify the supervisor. c. Call 911 immediately. d. Remove the client from the home immediately. Rationale: If a dangerous situation is encountered during a visit, the nurse should return to the agency and contact his or her supervisor or law enforcement officials, or both. Ignoring the husband or calling the police while in the home or attempting to remove the client from the home could further endanger the nurse and the client. 154. A 17-year-old girl has come to the free clinic for an annual examination. The client tells the nurse they use tampons and asks how long they may safely leave the tampon in place. What is the nurse's best response? a. "You may leave the tampon in overnight." b. "The tampon should be changed at least twice per day." c. "Tampons are dangerous and, ideally, you should not be using them." d. "Tampons need to be changed every 4 to 6 hours." Rationale: Tampons should not be used for more than 4 to 8 hours, nor should superabsorbent tampons be used because of the association with toxic shock syndrome. It is acceptable and safe for the client to use tampons if they are used appropriately. 155. While taking a health history on a 20-year-old female client, the nurse learns that the client is taking miconazole. The nurse is justified in presuming that this client has what medical condition? a. Bacterial vaginosis b. Human papillomavirus (HPV) c. Candidiasis d. Toxic shock syndrome (TSS) Rationale: Candidiasis is a fungal or yeast infection caused by strains of Candida. Miconazole (Monistat) is an antifungal medication used in the treatment of candidiasis. This agent is inserted into the vagina 2 c. Benign prostatic hyperplasia (BPH) d. Recurrent urinary tract infections (UTIs) ANS: B Rationale: The deep tendon reflexes of the knee are examined for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction because the sacral area, which innervates the lower extremities, is in the same peripheral nerve area responsible for urinary continence. Neurologic function does not directly influence the course of renal calculi, BPH or UTIs. 163. The nurse is caring for a 52-year-old client whose aunt and mother died of breast cancer. The client states, "My doctor and I talked about tamoxifen to help prevent breast cancer. Do you think it will work?" What would be the nurse's best response? a. "Yes, it's known to have a slight protective effect." b. "Yes, but studies also show an increased risk of osteoporosis." c. "You won't need to worry about getting cancer as long as you take tamoxifen." d. "Tamoxifen is known to be a highly effective protective measure." Rationale: Tamoxifen has been shown to be a highly effective chemo preventive agent. However, it cannot reduce the risk of cancer by 100%. It also acts to prevent osteoporosis. 164. A client has been diagnosed with Stevens-Johnson syndrome. Which factors are common triggers of this condition? Select all that apply. a. Tamoxifen and vemurafenib b. Exposure to cold objects, cold fluids, or cold air c. Allopurinol and nevirapine d. Wearing clothing washed in a detergent e. Radiation in combination with phenytoin Rationale: Stevens-Johnson syndrome is a severe reaction commonly triggered by medication. The syndrome can evolve into extensive epidermal necrosis and become life-threatening. Among the many medications that trigger this condition are tamoxifen, vemurafenib, allopurinol and nevirapine. The combination of radiation and antiepileptic drugs such as phenytoin can also trigger this condition. Exposure to cold objects, cold fluids, or cold air can trigger cold urticaria, resulting in wheals (hives) or angioedema, but would not trigger Steven-Johnson syndrome. Wearing clothing washed in a detergent can trigger contact dermatitis but would not trigger Steven-Johnson syndrome. 165. A female client with large uterine fibroids is scheduled for a hysterectomy next month and is started on leuprolide. The client requests information about the medication’s route, duration of treatment and any side effects. What is the nurse’s best response? a. This medical regimen will consist of weekly subcutaneous injections. b. This is a medication that works best if taken consistently over a long period of time. c. The medication induces a temporary menopause-like environment in the body. d. The medication may temporarily increase vaginal secretions creating an environment for bacterial growth. 2 Rationale: Leuprolide is in a class of medications called gonadotropin releasing hormone agonists. It essentially reduces the amount of estrogen in women. Leuprolide induces a temporary menopausal-like environment that helps shrink the fibroids. Treatments consist of monthly injections, which may cause hot flashes and vaginal dryness. This treatment allows easier surgery and alleviates anemia. Treatment is typically temporary due to vasomotor symptoms and loss of bone density. 166. A 35-year-old father of three tells the nurse that they want information on a vasectomy. What would the nurse tell the client about ejaculate after a vasectomy? a. There will be no ejaculate after a vasectomy, though the client's potential for orgasm is unaffected. b. There is no noticeable decrease in the amount of ejaculate even though it contains no sperm. c. There is a marked decrease in the amount of ejaculate after vasectomy, though this does not affect sexual satisfaction. d. There is no change in the quantity of ejaculate after vasectomy, but the viscosity is somewhat increased. Rationale: Seminal fluid is manufactured predominantly in the seminal vesicles and prostate gland, which are unaffected by vasectomy, thus no noticeable decrease in the amount of ejaculate occurs (volume decreases approximately 3%), even though it contains no spermatozoa. The viscosity of ejaculate does not change. 167. A clinic nurse is providing preprocedural education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply. a. Abstaining from sexual intercourse for at least 14 days’ post procedure b. Wearing a scrotal support garment c. Using sitz baths d. Applying a heating pad intermittently e. Staying on bed rest for 48 to 72 hours’ post procedure Rationale: Applying ice bags intermittently to the scrotum for several hours after surgery can reduce swelling and relieve discomfort and is preferable to the application of heat. The nurse advises the client to wear snug, cotton underwear or a scrotal support for added comfort and support. Sitz baths can also enhance comfort. Extended bed rest is unnecessary, and sexual activity can usually be resumed in 1 week. 168. A client has just returned to the floor following a transurethral resection of the prostate. A triple-lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens? a. Continuous inflow and outflow of irrigation solution b. Intermittent inflow and continuous outflow of irrigation solution c. Continuous inflow and intermittent outflow of irrigation solution d. Intermittent flow of irrigation solution and prevention of hemorrhage 2 Rationale: For continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution. 169. A nurse is providing care for a client who has recently been admitted to the postsurgical unit from PACU following a transurethral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action? a. Closely monitoring the input and output of the bladder irrigation system b. Administering parenteral nutrition and fluids as prescribed c. Monitoring the client's level of consciousness and skin turgor d. Scanning the client's bladder for retention every 2 hours Rationale: Continuous bladder irrigation effectively reduces the risk of clots in the GU tract but also creates a risk for fluid volume excess if it becomes occluded. The nurse must carefully compare input and output and ensure that these are in balance. Parenteral nutrition is unnecessary after prostate surgery and skin turgor is not an accurate indicator of fluid status. Frequent bladder scanning is not required when a urinary catheter is in situ. 170. A client has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The client has a continuous bladder irrigation system in place. The client reports bladder spasms. What is the most appropriate nursing action to relieve the discomfort of the client? a. Apply a cold compress to the pubic area. b. Notify the urologist promptly. c. Irrigate the catheter with 30 to 50 mL of normal saline as ordered. d. Administer a smooth-muscle relaxant as ordered. Rationale: Administering a medication that relaxes smooth muscles can help relieve bladder spasms. Neither a cold compress nor catheter irrigation will alleviate bladder spasms. In most cases, this problem can be relieved without the involvement of the urologist, who will normally order medications on a PRN basis. 171. A 16-year-old male client comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the client to seek care? a. The emergence of a chancre on his penis b. Painful urination c. Signs of a systemic infection d. Unilateral testicular swelling ANS: A Rationale: Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless chancre develops at the site of infection. Initial infection with syphilis is not associated with testicular swelling, painful voiding, or signs of systemic infection. 172. A nurse is educating a group of students about stages of syphilis. Which is true for secondary syphilis? a. Chancres will resolve without treatment. 2 178. A nurse practitioner is assessing a 55-year-old male client who reports perineal discomfort, burning, urgency, and frequency with urination. The client states that he has pain with ejaculation. The nurse knows that the client is exhibiting symptoms of: a. Varicocele. b. Epididymitis. c. Prostatitis. d. Hydrocele. Rationale: Perineal discomfort, burning, urgency, frequency with urination, and pain with ejaculation are indicative of prostatitis. A varicocele is an abnormal dilation of the pampiniform venous plexus and the internal spermatic vein in the scrotum (the network of veins from the testis and the epididymis that constitute part of the spermatic cord). Epididymitis is an infection of the epididymis that usually descends from an infected prostate or urinary tract; it may also develop as a complication of gonorrhea. A hydrocele is a collection of fluid, generally in the tunica vaginalis of the testis, although it may also collect within the spermatic cord. 179. A male client with gonorrhea asks the nurse how they can reduce the risk of contracting another sexually transmitted infection (STI). The client is not in a monogamous relationship. The nurse should instruct the client to do what action? a. Ask all potential sexual partners if they have an STI. b. Wear a condom every time the client has intercourse. c. Consider intercourse to be risk-free if the partner has no visible discharge, lesions, or rashes. d. Aim to limit the number of sexual partners to fewer than five over their lifetime. Rationale: Wearing a condom during intercourse considerably reduces the risk of contracting a sexually transmitted infection (STI). The other options may help reduce the risk for contracting an STI, but not to the extent that wearing a condom will. A monogamous relationship reduces the risk of contracting STIs. 180. A client is receiving treatment for a new diagnosis of chronic lymphocytic leukemia (CLL). Based on known risk factors, age, ethnicity, and accompanying clinical conditions, which client is most likely to have this disease? a. 82-year-old Vietnam War veteran with widely disseminated shingles b. 62-year-old client of Asian descent with a left fractured hip c. 69-year-old Gulf War veteran with deep vein thrombosis (DVT) d. 85-year-old client of Native American/First Nation descent with chest pain Rationale: CLL is a common malignancy of older adults with an average age of 71 at diagnosis and the most prevalent leukemia in the Western world. It is rarely seen in clients of Native American/First Nation descent and has an infrequent incidence in clients of Asian descent. Veterans of the Vietnam War who were exposed to the herbicide Agent Orange are at risk for CLL. The time period of exposure was from 1962 to 1975 so veterans from the Gulf War in 1991 were not exposed. Infections are common with advanced CLL. None of the other conditions are related to infection, so they are not the best choice. Viral infections such as herpes zoster (shingles) can be widely disseminated with CLL. 2 181. A client's exposure to which microorganism is most likely to trigger a cellular response? a. Herpes simplex b. Staphylococcus aureus c. Pseudomonas aeruginosa d. Beta-hemolytic Streptococcus Rationale: Viral, rather than bacterial, antigens induce a cellular response. Herpes simplex is a virus. Staphylococcus aureus, Pseudomonas aeruginosa, and beta-hemolytic Streptococcus are all bacteria. 182. A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS? a. Risk for disuse syndrome related to Kaposi sarcoma b. Impaired skin integrity related to Kaposi sarcoma c. Diarrhea related to Kaposi sarcoma d. Impaired swallowing related to Kaposi sarcoma Rationale: Kaposi sarcoma is a type of cancer caused by human herpesvirus-8 that involves the epithelial layer of blood and lymphatic vessels. It exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs, which may be the first manifestation of HIV, can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome. 183. A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis. a. Herpes simplex b. Human immunodeficiency virus (HIV) c. Spina bifida d. Hypogammaglobulinemia Rationale: Clients with spina bifida are at a particularly high risk for developing a latex allergy. Clients with spina bifida are at high risk because they have had multiple surgeries, multiple urinary catheterization procedures, and other treatments involving use of latex products, and latex allergy develops as a result of repeated exposure to the proteins and polypeptides in natural rubber latex. Clients with herpes simplex, HIV, or hypogammaglobulinemia (decreased level of gamma immunoglobulins) are less likely than clients with spina bifida to have as many surgeries as possible or other treatments that would expose them to latex. 184. A nurse is caring for a pregnant client with active herpes. The teaching plan for this client should include which of the following? a. Babies delivered vaginally may become infected with the virus. 2 b. Recommended treatment is excision of the herpes lesions. c. Pain generally does not occur with a herpes outbreak during pregnancy. d. Pregnancy may exacerbate the pregnant client's symptoms but poses no risk to the infant. Rationale: In pregnant women with active herpes, babies delivered vaginally may become infected with the virus. There is a risk for fetal morbidity and mortality if this occurs. Lesions are not controlled with excision. Itching and pain accompany the process as the infected area becomes red and swollen. Aspirin and other analgesics are usually effective in controlling the pain. 185. A client with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection? a. Clotrimazole b. Metronidazole c. Podophyllin d. Acyclovir Rationale: Acyclovir is an antiviral agent that can suppress the symptoms of genital herpes and shorten the course of the infection. It is effective at reducing the duration of lesions and preventing recurrences. Clotrimazole is used in the treatment of yeast infections. Metronidazole is the most effective treatment for trichomoniasis. Podophyllin is used to treat external genital warts. Acyclovir is used in the treatment of genital herpes. 186. A client has herpes simplex 2 viral infection (HSV-2). The nurse recognizes that which of the following should be included in teaching the client? a. The virus also causes "cold sores" of the lips. b. The virus may be cured with topical antibiotics. c. The client's family history is an important part of assessment. d. Treatment is aimed at relieving symptoms. Rationale: HSV-2 causes genital herpes and is known to ascend the peripheral sensory nerves and remain inactive after infection, becoming active in times of stress. The virus is not curable, but treatment is aimed at controlling symptoms. HSV-1 causes "cold sores," and varicella zoster causes shingles. Family history is not relevant because the infection is viral. 187. The nurse is caring for a client who has been diagnosed with genital herpes. When preparing a teaching plan for this client, what general guidelines should be taught? a. Thorough handwashing is essential. b. Exposure to ultraviolet light assists in eradicating the virus. c. Lesions should be gently massaged with ointment. d. Self-infection cannot occur from touching lesions during a breakout. Rationale: The risk of reinfection and spread of infection to others or to other structures of the body can be reduced by handwashing, use of barrier methods with sexual contact, and adherence to prescribed medication regimens. The lesions should be allowed to dry. Touching of lesions during an outbreak 2 continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses. 195. A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? a. Initiating a client-controlled analgesia (PCA) of morphine sulfate b. Administering hydromorphone IV as needed c. Dimming the lights and reducing stimulation d. Distracting the client with activity Rationale: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective and may exacerbate the client's pain. 196. A nurse is preparing a presentation for a local high school health class about STIs. When discussing the most commonly reported STIs, which infection would the nurse most likely include? Select all that apply. a. Chlamydia b. Gonorrhea c. Human Papilloma Virus infection d. Herpes simplex 2 virus infection e. Syphilis Rationale: Chlamydia trachomatis and Neisseria gonorrhea are the most commonly reported STIs. Human papillomavirus (HPV) infection is the most common STI among young, sexually active people. Millions of Americans are infected wit 197. A client is receiving treatment for a new diagnosis of chronic lymphocytic leukemia (CLL). Based on known risk factors, age, ethnicity, and accompanying clinical conditions, which client is most likely to have this disease? a. 82-year-old Vietnam War veteran with widely disseminated shingles b. 62-year-old client of Asian descent with a left fractured hip c. 69-year-old Gulf War veteran with deep vein thrombosis (DVT) d. 85-year-old client of Native American/First Nation descent with chest pain Rationale: CLL is a common malignancy of older adults with an average age of 71 at diagnosis and the most prevalent leukemia in the Western world. It is rarely seen in clients of Native American/First Nation descent and has an infrequent incidence in clients of Asian descent. Veterans of the Vietnam War who were exposed to the herbicide Agent Orange are at risk for CLL. The time period of exposure was from 1962 to 1975 so veterans from the Gulf War in 1991 were not exposed. Infections are common with advanced CLL. None of the other conditions are related to infection, so they are not the best choice. Viral infections such as herpes zoster (shingles) can be widely disseminated with CLL. 198. A client's exposure to which microorganism is most likely to trigger a cellular response? a. Herpes simplex 2 b. Staphylococcus aureus c. Pseudomonas aeruginosa d. Beta-hemolytic Streptococcus Rationale: Viral, rather than bacterial, antigens induce a cellular response. Herpes simplex is a virus. Staphylococcus aureus, Pseudomonas aeruginosa, and beta-hemolytic Streptococcus are all bacteria. 199. A female client has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this client? a. The warts may require surgical removal or cryotherapy b. The most common treatment is metronidazole, which should eradicate the problem within 7 to 10 days. c. The potential for transmission to the sexual partner will be eliminated if condoms are used every time, they have sexual intercourse. d. The human papillomavirus (HPV), which causes condylomata acuminata, cannot be transmitted during oral sex. Rationale: Options for treatment of external genital warts by a primary provider include topical application of trichloroacetic acid, podophyllin (Podofin, Podocon), cryotherapy, and surgical removal. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom will not protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. 200. A client with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection? a. Clotrimazole b. Metronidazole c. Podophyllin d. Acyclovir Rationale: Acyclovir is an antiviral agent that can suppress the symptoms of genital herpes and shorten the course of the infection. It is effective at reducing the duration of lesions and preventing recurrences. Clotrimazole is used in the treatment of yeast infections. Metronidazole is the most effective treatment for trichomoniasis. Podophyllin is used to treat external genital warts. Acyclovir is used in the treatment of genital herpes. 201. A 76-year-old with a diagnosis of penile cancer has been admitted to the medical floor. Because the incidence of penile cancer is so low, the staff educator has been asked to teach about penile cancer. What risk factors should the educator cite in this presentation? Select all that apply. a. Phimosis b. Priapism c. Herpes simplex infection d. Increasing age 2 e. Lack of circumcision Rationale: Several risk factors for penile cancer have been identified, including lack of circumcision, poor genital hygiene, phimosis, HPV, smoking, ultraviolet light treatment of psoriasis on the penis, increasing age (two thirds of cases occur in men older than 65 years of age), lichen sclerosus, and balanitis xerotica obliterans. Priapism and HSV are not known risk factors. 202. When teaching clients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor? a. Late childbearing b. Human papillomavirus (HPV) c. Postmenopausal bleeding d. Tobacco use Rationale: HPV is the most salient risk factor for cervical cancer, exceed