NUR257 EXAM 3 EXAM 2024-2025, Exams of Nursing

Download NUR257 EXAM 3 EXAM 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e NUR257 EXAM 3 EXAM 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS|FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST |GUARANTEED PASS|LATEST UPDATE A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status? A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement b The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A) Absence of pain response B) Apnea C) Coma D) Absence of brain stem reflexes E) Absence of deep tendon reflexes b,c,d Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma. 2 | P a g e b The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A) Promoting adequate circulation B) Treating the child's increased ICP C) Assessing secondary brain injury D) Preserving brain homeostasis d A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound a A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has? A) Diffuse axonal injury B) Grade 1 concussion with frontal lobe involvement C) Contusion D) Grade 3 concussion with temporal lobe involvement d An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? A) Hematoma B) Skull fracture C) Embolus D) Stroke a A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patient's care should the nurse begin to use a neurologic flow chart? A) When the patient's condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patient's condition b 5 | P a g e A) At the patient's request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises C A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage. A A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP A,B,C The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered C A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously C A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority 6 | P a g e medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone) C The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control B The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A) Position the patient in the high Fowler's position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy C The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated. B) Monitor serum electrolytes. C) Maintain NPO status. D) Monitor arterial blood gas (ABG) values. B 7 | P a g e A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing. D A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered C A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig) C The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses. D A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale 10 | P a g e D During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level. D Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patient's current LOC? A) The patient occasionally makes incomprehensible sounds. B) The patient's current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations C The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patient's life. C) Teach the family proper care of the patient. D) Provide community assistance. A The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A) The ability of the patient to follow instructions during the seizure. B) The success or failure of the care team to physically restrain the patient. C) The patient's ability to explain his seizure during the postictal period. D) The patient's activities immediately prior to the seizure. D The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient? A) Assessing the patient's verbal response B) Assessing the patient's ability to follow complex commands 11 | P a g e C) Assessing the patient's judgment D) Assessing the patient's response to pain A The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia A,C,D,E The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide C The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patient's LOC. C) Increase the patient's bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered. A A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes D 12 | P a g e A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure C When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? A) Fluid restriction B) Transfusion of platelets C) Transfusion of fresh frozen plasma (FFP) D) Electrolyte restriction A The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? Select all that apply. A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) Electromyelography (EMG) A,B,C A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A) Administer morphine sulfate as ordered. B) Reposition the patient in a prone position. C) Apply a hot pack to the patient's scalp. D) Implement distraction techniques. A A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? A) Cerebellum 15 | P a g e A) Place the patient in the prone position for 30 minutes/day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patient's hand in pronation. C A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA C The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation C When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath B The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic 16 | P a g e stroke? A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking B A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance A A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A) Range-of-motion exercises to prevent contractures B) Encouraging independence with ADLs to promote recovery C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment D A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? A) The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B) Elevation of the arm and hand can lead to further complications associated with edema. C) Passively exercising the affected extremity is avoided in order to minimize pain. D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. D The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. 17 | P a g e C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient. A The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting A The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? A) The patient's hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion. C A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings. B A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. 20 | P a g e B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence. A A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization. B A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A) How to differentiate between hemorrhagic and ischemic stroke B) Risk factors for ischemic stroke C) How to correctly modify the home environment D) Techniques for adjusting the patient's medication dosages at home C After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? A) Administer a bolus of normal saline as ordered. B) Prepare the patient for thrombolytic therapy as ordered. C) Facilitate testing for hypothalamic dysfunction. D) Prepare to administer 3% NaCl by IV as ordered. D A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? A) Female gender B) Asian American race C) Advanced age D) Smoking 21 | P a g e C A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet. B The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN C A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration. D Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patient's hygiene and feeding. A A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? 22 | P a g e A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block B The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534 236145 As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission B,D,E After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? 25 | P a g e A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia b The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea a A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out", but came to and "seemed okay". Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives C) Emergency craniotomy D) Administration of anticoagulant therapy c The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature. b An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents 26 | P a g e d A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises b Paramedics have brought an intubated patient to the RD following a head injury due to acceleration- deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour. c A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A) Preparation for emergency craniotomy B) Watchful waiting and close monitoring C) Administration of inotropic drugs D) Fluid resuscitation b A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded. d A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day c 27 | P a g e A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A) Restrain the patient as ordered. B) Administer opioids PRN as ordered. C) Arrange for friends and family members to sit with the patient. D) Pad the side rails of the patient's bed. d A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries a A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia c An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents b A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities a A patient is not have daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use? 30 | P a g e When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be: A. reporting pain relief B. maintaining body weight. C. maintaining fluid balance D. reestablishing a normal bowel pattern C. maintaining fluid balance A client is recently diagnosed with Crohn's disease and is beginning treatment. What the first-line treatment does the nurse expect that the client will be placed on to decrease the inflammatory response? A. Ciprofloxacin B. Methotrexate C. Azathroprine D. Sulfasalazine D. Sulfasalazine During assessment of a client for a malabsorption disorder, the nurse notes a history of abdominal pain and weight loss, marked steatorrhea, azotorrhea, and frequent glucose intolerance. Based on these clinical features, what diagnosis will the nurse suspect? A. Lactose intolerance B. Celiac disease C. Pancreatic insufficiency D. Ileal dysfunction C. Pancreatic insufficiency The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve? A. 2 in. B. 3 in C. 4 in. D. 5 in. A. 2 in. What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? (select all that apply). A. Sudden, sustained abdominal pain B. abdominal distention 31 | P a g e C. sudden drop in body temperature D. intermittent, severe pain B. abdominal distention Which of the following is accurate regarding regional enteritis? A. Fistulas are common B. Severe diarrhea C. Severe bleeding D. Exacerbation and remissions D. Exacerbation and remissions what is the most common cause of small-bowel obstruction? A. Hernias B. Neoplasma C. Adhesions D. Volvulus C. Adhesions A client presents to the emergency room with a possible diagnosis of appendicitis. The health care provider asks the nusrse to assess for tenderness at McBurney's point. The nurse knows to palpate which area? A. Between the umbilicus and the left iliac crest B. Between the imnilicus and the anterior superior iliac spine C. In the left periumbilical area D. In the upper right quadrant slightly below the diaphragm B. Between the imnilicus and the anterior superior iliac spine A client present to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated causing the clinet to reprot pain the int RLQ. This psoitive sign is referred to as ____________ and suggests the client may be experiencing ____________. A. Rovsing's sign; acute appendicitis b. McBurney's sign; acute appendicitis C. Rovsing's sign; perforation D. McBurney's sign; perforation A. Rovsing's sign; acute appendicitis A client suspected of having colorectal cancer requires requires which diagnostic study to confirm the diagnosis? 32 | P a g e A. Stool Hematest B. Carcinoembryonic antigen C. Sigmiodoscopy D. Abdominal computed tomography (CT) scan C. Sigmiodoscopy The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be A. Semimushy B. mushy C. fluid D. solid D. solid A nurse is performing focused assessment on her clients. she expects to hear hypoactive bowel sounds in a client with: A. paralytic ileus B. Crohn's disease C. gastrogenteritis D. complete bowel obstruction A. paralytic ileus A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress A. High levels of alcohol consumption A nurse is caring for an older adult who has been experiencing severe clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level D. Potassium level 35 | P a g e C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence B. Foul-smelling diarrhea that contains fat The nurse is creating a discharge plan of care for a client with a peptic ulcer. The nurse tells the client to avoid A. acetaminophen B. decaffeinated coffee C. Skim milk D. octreotide B. decaffeinated coffee The nurse is teaching a client who has experienced an episode of acute gastritis. The nurse knows further education is necessary when the client makes which statement? A. "I should feel better in about 24 to 36 hours." B. "My appetite should come back tomorrow." C. "I should limit alcohol intake, at least until symptoms subside." D. "Once i can eat again, I should stick with bland foods." B. "My appetite should come back tomorrow." A client with peptic ulcer disease wants to known nonpharmacologic ways to prevent recurrence. Which of the following measures would the nurse recommend? Select all that apply A. Smoking cessation B. Substitution of coffee with decaffeinated products C. Avoidance of alcohol D. Eating whenever hungry E. Following a regular schedule for rest, relaxation, and meals A. Smoking cessation C. Avoidance of alcohol E. Following a regular schedule for rest, relaxation, and meals A client who is being treated for pyloric obstruction has nasogastric (NG) tube in place to decompress the stomach. The nurse routinely checks for obstruction which would be indicated by what amount? A. 150 ml B. 250 ml C. 350 ml D. 450 ml D. 450 ml 36 | P a g e A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? A. Notify the health care provider B. Reposition the tube C. Irrigate the tube D. Increase the suction level A. Notify the health care provider The health care provider prescribes a combination of three drugs to treat peptic ulcer disease. The nurse, preparing to review the drug actions and side effects with the patient, understands that the triple combination should be in which order? A. Antibiotics, prostaglandin E1 analogs, and bismuth salts B. Proton pump inhibitors, prostaglandin E1 analogs, and bismuth salts C.Bismuth salts, antibiotics, and proton pump inhibitor D. Prostaglandin E1 analogs, antibiotics, and proton pump inhibitors C.Bismuth salts, antibiotics, and proton pump inhibitor A client has recently been diagnosed with gastric cancer. On palpation, the nurse would note what two signs that confirm metastasis to the liver? Select all that apply. A. Ascites B. Hepatomegaly C. Distented bladder D. Sister Mary Joseph's nodules E. Petechiae at the palpation site A. Ascites B. Hepatomegaly Which statement correctly identifies a difference between duodenal and gastric ulcer? A. Malignancy is associated with duodenal ulcer B. Weight gain may occur with a gastric ulcer C. A gastric ulcer is caused by hypersecretion of stomach acid D. Vomiting is uncommon is clients with duodenal ulcers. D. Vomiting is uncommon is clients with duodenal ulcers. The nurse is caring for a patient who has been diagnosed with gastritis. TO promote fluid balance when treating gastritis, the nurse knows that what minimal daily intake of fluids is required? A. 1.0 L B 1.5 L 37 | P a g e C. 2.0 L D. 2.5 L B 1.5 L During assessment of a patient with gastritis, the nurse practitioner attempts to distinguish acute from chronic pathology. One criteria, characteristic of gastritis would be the: A. Immediacy of the occurrence B. Presence of vomiting C. Frequency of abdominal discomfort D. Incidence of anorexia A. Immediacy of the occurrence Which diagnostic test would be used first to evaluate a cleint with upper GI bleeding? A. Upper GI series B. Endoscopy C. Hemoglobin and hematocrit D. Arteriography C. Hemoglobin and hematocrit Which of the following is the most common complication associated with peptic ulcer? A. Hemorrhage B. Vomiting C. Elevated temperature D. Abdominal pain A. Hemorrhage A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply. A. Tachycardia B. Hypotension C. Mild epigastric pain D. A rigid, board-like abdomen E. Diarrhea A. Tachycardia B. Hypotension D. A rigid, board-like abdomen A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is 40 | P a g e C. It protects the stomach's lining D. It increase lower esophageal sphincter pressure. C. It protects the stomach's lining A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12 D. Administration of injections of vitamin B12 The nursing student approaches his instructor ti discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following? A. Duodenum B. Esophagus C. Pylorus D. Stomach A. Duodenum A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly B. The client has a rigid, "boardlike" abdomen that is tender C. The client is experiencing intense lower right quadrant pain D. The client is experiencing dizziness and confusion with no apparent hymodynamic changes. B. The client has a rigid, "boardlike" abdomen that is tender The client has been taking famotidine (Pepcid) at home. The nurse prepares a taching plan for the client indicating that the medication acts primarily to achieve which of the following? A. Inhibit gastric acid secretions B. Neutralize acid in the stomach C. Shorten the time required for digestion in the stomach D. Improve the mixing of foods and gastric secretions 41 | P a g e A. Inhibit gastric acid secretions A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis. C. Smokes one pack of cigarettes daily. A client with peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen? A. "My ulcer will heal because these medications will kill the bacteria." B. "I should take these medications only when I have pain from my ulcer." C. "The medications will kill the bacteria and stop the acid production." D. "These medications will coat the ulcer and decrease the acid production in my stomach." C. "The medications will kill the bacteria and stop the acid production." The nurse is cautiously assessing a client admitted with peptic ulcer disease because the most common complication that occurs in 10% to 20% of clients is: A. Hemorrhage B. Intractable ulcer C. Perforation D. Pyloric obstruction A. Hemorrhage A client's physician has determined that for the next 3 to 4 weeks the client will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A. Peripheral catheter B. Nontunneled central catheter C. Implantable port D. Tunneled central catheter B. Nontunneled central catheter A client with gastric cancer is having a resection. What is the nursing management priority for the client? A.Discharge planning B. Correcting nutritional deficits 42 | P a g e C. Preventing deep vein thrombosis (DVT) D. Teaching about radiation treatment B. Correcting nutritional deficits The nurse is caring for a client who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed? A. 2 weeks B. 4 to 6 weeks C. 1 1/2 to 3 months D. 4 to 6 months C. 1 1/2 to 3 months The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? A. Administer prescribed metoclopramide. B. Have the client lay on the left side. C. Assist the client to drink 8 ounces of water. D. Instruct the client to swallow several times. A. Administer prescribed metoclopramide. After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement? A. I need to keep my head turned directly toward you and the health care provider B. I will be laying on my back buck my legs will be high than my head C. I will need to take long, slow, deep breaths when the catheter is inserted. D. I'll have to wear a thick, bulky dressing over the site. B. I will be laying on my back buck my legs will be high than my head A nurse is participating in a client's care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What adcantages are associated with providing TNA rather than PN? A. TNA can be mixed by a certified registered nurse. B. TNA can be given over 8 hours, while PN requires 24-hour administration. C. TNA is less costly than PN D. TNA does not require the use of a micron filter C. TNA is less costly than PN The nurse is caring for a client who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? 45 | P a g e DNA changes: each time a cell undergoes mitosis, the telomeres on the ends of the chromosome shorten slightly and eventually this loss of telomeres stops the ability of chromosomes to replicate Intrinsic Mutagenesis the process by which telomeres on the ends of chromosomes shorten slightly Wear and Tear Theories of Aging errors in the replication of cells and accumulation of damaging byproducts eventually leads to declining cellular function and aging Free Radical/Oxidative Stress Theory secondary to the buildup of unstable oxygen compounds, there is cumulative damage to cells and tissues as a result of aerobic metabolism In the Free Radical/Oxidative Stress Theory, environmental oxidizing agents cause harm to what structures in cells and tissues? Cell membranes and cells What do antioxidant enzymes do in relation to the Free Radical/Oxidative Stress Theory? Antioxidants can be derived from a healthy diet or from phytochemicals which block the formation of free radicals phytochemicals plant chemicals What are the effects and physiological changes of Normal Aging? 1) LBM 2) Sarcopenia 3) Proportion Distortion 4) Weight Gain 5) Decline in taste, smell, appetite, and thirst 6) Decline in oral health LBM (lean body mass) sum of fat free tissues comprising bone, muscle, and water Sarcopenia age-associated loss of skeletal muscle mass and function Proportion distortion refers to the growing proportion sizes people call normal as age increases, the number of calories required (decreases/increases) 46 | P a g e Decreases Are carbs typically a nutritional risk factor in older adults? No What is the daily recommended intake of fiber for older adults? 22-28 g/day recommended What is the daily recommended intake of protein for older adults? 1-1.5 g/kg What is the most common deficiency among older adults? Protein Nitrogen balance the difference between intake and loss of protein What is the second most common deficiency among older adults? dairy What percent of total calories should be used by fats for older adults? 20-35% What is the DRI Water/Fluid Recommendation for older adults? 1 mL of fluid per calorie eaten or a minimum of 1500 mL of fluid/day What are the nutrients of concern associated with aging? Fiber, Iron, B12, and water Vitamin A antioxidant; organic compound including retinol and retinoic acid which is important to vision, growth, and cell division can fat-soluble vitamins exit the body through urine? NO What Vitamin is an area of concern for the elderly? Vitamin D Vitamin D/Calciferol (Vitamin D12) Fat-soluble vitamin that increases intestinal absorption of calcium, magnesium, and phosphate A deficiency of what vitamin is rare? 47 | P a g e Vitamin E Vitamin E Alpha-tocopherol which acts as an antioxidant to enhance immune function and competes with vitamin K Vitamin K Reduces or inhibits blood clotting How does the drug warfarin or coumadin interact with Vitamin K? Warfarin is used to prevent dangerous blood clots, however, Vitamin K can make warfarin less effective because warfarin prolongs blood clotting. Warfarin works by blocking a Vitamin K step in clotting factor production Which blood anti-coagulation drugs interact with Vitamin K? Apixaban and Eliquis is Vitamin B 12 water or fat-soluble? Water-soluble Why would Vitamin B 12 absorption be hindered? What is the prevalence? Absorption can be hindered by the GI system due to decreased HCL production. This affects 30% of older adults Atrophic Gastritis thinning of the stomach lining What is folate? What is it associated with in older adults? Folate is a type of Vitamin B and a deficiency of folate is associated with anemia What is an iron deficiency in older adults associated with? Low caloric intake, disease, and medications Why is calcium important for older adults? It is central to bone health and contraction of the muscles and heart Why is magnesium important for older adults? It supports muscle and nerve function and is important to the the health of teeth, and synthesis of fats, proteins, and glucose What is the daily recommended value of Sodium for older adults? not exceeding 1200 mg/day 50 | P a g e last 20 weeks of pregnancy: increased insulin resistance leads to increases in maternal glucose and free fatty acid concentrations, allowing for a greater substrate availability for fetal growth When are blood, oxygen, glucose, amino acids, and nutrients delivered to the fetus? the Catabolic Phase During pregnancy, there are physiological changes in which metabolisms? 1) carbohydrate metabolism 2) protein metabolism 3) fat metabolism 4) mineral metabolism What is the preferred fuel for fetuses? glucose How is carbohydrate metabolism characterized in the first half of pregnancy? Estrogen and progesterone are stimulated to increase insulin production and the conversion of glucose to glycogen and fat How is carbohydrate metabolism characterized in the second half of pregnancy? Rising levels of hCS and prolactin inhibit the conversion of glucose to glycogen and fat hCS human chorionic somatropin Are there issues with protein metabolism during pregnancy? No, maternal and fetal needs for protein are met by the mother's intake of protein during pregnancy How does fat metabolism change during pregnancy? Changes in lipid metabolism promote the accumulation of maternal fat stores in the first half of pregnancy and enhance fat mobilization in the second half of pregnancy How does mineral metabolism change during pregnancy? It changes to provide the fetus with calcium needed for bone formation, maternal absorption of calcium and the rate of calcium mobilization from bone increases What is the sodium balance between during pregnancy? Mother, placenta, and fetus What percent of glucose delivered by maternal circulation is used by the placenta? 30-40% if glucose and nutrient needs are low, will the glucose go towards the placenta or fetus? 51 | P a g e Placenta What does nutrient transfer across the placenta depend on? 1) Size and charge of molecules available for transport 2) Lipid solubility 3) Concentration of nutrients in maternal and fetal blood When are critical periods in pregnancy most intense? During the first 2 months after conception when a majority of organs and tissues begin to form What is the first organ to develop in fetuses? The brain and CNS Why do energy requirements during pregnancy increase? Protein and Fat Tissue synthesis In the first trimester of pregnancy, how many additional calories should a woman consume? 300 additional cal/day In the second trimester of pregnancy, how many additional calories should a woman consume? 340 cal/day In the third trimester of pregnancy, how many additional calories should a woman consume? 452 cal/day The need for what nutrients increase during pregnancy? 1) Fat by 33% 2) Increased Protein need 3) Carbs maintained at 45-65% What is the minimum daily carb requirement for pregnant women? 175 g What is the recommended intake of protein during pregnancy? 71 g miscarriage loss of embryo before 20 weeks of pregnancy What percent of embryos are loss to miscarriage? over 30% preterm delivery 52 | P a g e before the estimated due date, infants born before 34 weeks are at a high risk for serious complications and is considered a major health problem in the US what is typically the normal weight gain for women? 25-35 lbs What should be the weight gain during pregnancy for underweight women? up to 40 lbs What should be the weight gain during pregnancy for overweight women? 20 lbs What is the target weight gain during the first trimester? 3-5 lb weight gain When is the rate of weight gain for a pregnant woman highest? mid-pregnancy What is protein metabolism used for during pregnancy? It is less used for energy and more used for protein synthesis which occurs in fetal, placental, uterine, and breast tissue What is the goal weight of a baby at the time of delivery? 3500 grams or 7 lbs 11 oz Postpartum weight retention is prevalent for women who gain how much weight during pregnancy? For women who gained more than 44 lbs during pregnancy Women with recommended weight gain during pregnancy are how much heavier at 1 year postpartum? 2 lbs heavier how much weight should a woman aim to lose postpartum with appropriate diet and exercise? 1-2 lbs/month What serve as structural components of cell membranes? Fatty acids EPA (eicosapentaenoic acid) and DHA (docosahexanoic acid) What parts of the fetus need the fatty acids EPA and DHA? Brain, retina, and other neural tissues Where is EPA and DHA found? What is the adequate intake recommended? It is found in seafood: the adequate intake is 300 mg/day 55 | P a g e Human milk is the only food needed by most healthy infants for how long? The first 6 months: it nurtures and protects from infectious disease how does the composition of human milk change over a single feeding? Based on infant age, presence of infection, with menses, and maternal nutritional status Lactogenesis production of milk What are the stages of Lactogenesis? Lactogenesis I Lactogenesis II Lactogenesis III Lactogenesis I first few days after birth where milk formation begins that are high in proteins like secretory IgA and lactoferrin Lactogenesis II 2-5 days after birth where there is increased in blood flow to breast and the milk comes in Lactogenesis III 10 days after birth where milk composition is stable Lactation is controlled by which hormones? Prolactin and Oxytocin Prolactin hormone that promotes milk production and is stimulated by suckling Oxytocin responsible for ejection of milk from the milk gland and is stimulated by suckling or nipple stimulation What are the components of breast milk? Water Energy Lipids Proteins Milk Carbohydrates Fat Soluble Vitamins Water Soluble Vitamins Minerals 56 | P a g e What is the small intestine, what is it responsible for, and what parts does it have? longest portion of GI tract responsible for absorption and secretion duodenum, jejunum, and terminal ileum Where is iron absorbed in the body? duodenum of the small intestine Where is folate absorbed in the body? jejunum of the small intestine Where is B12 absorbed in the body? terminal ileum of the small intestine What is the large intestine responsible for and what parts does it have? reabsorption of water ascending, transverse, descending, and sigmoid colon Where does the large intestine receive blood from? superior and inferior mesenteric arteries Where does the small intestine receive blood from? celiac artery Where does blood go after going through the GI tract? liver which is why most GI cancers metastasize to the liver What does bile do, where is it produced in the body, and where is it stored? bile breaks down and emulsifies fat it is produced in the liver it is stored in the gallbladder What is salivary amylase responsible for? breakdown of starches What is pepsin responsible for? breaking down proteins into amino acids What is intrinsic factor important for? B12 absorption What is lipase responsible for? 57 | P a g e breaking down fats What is trypsin responsible for? digesting proteins Where does a patient feel pain for appendicities? right lower quadrant McBurney's point Where does a patient feel pain for pancreatitis? left shoulder Where does a patient feel pain for cholecystitis, pancreatitis, and duodenal ulcer? right upper quadrant What are CEA and CA 19-9 labs studies for? they are tumor markers and are associated with colorectal cancer What is the breath test? urease breath test for H. pylori What is sialolithiasis? salivary stones What are risk factors for oral cancer? tobacco use, alcohol, HPV infection, history of head and neck cancer What occurs during the early stage of oral cancer? few or not symptoms painless sore or mass that does not heal indurated ulcer may bleed easily and present with red or white patche What occurs during the late stage of oral cancer? complaints of tenderness difficulty in chewing, swallowing, or speaking coughing up blood-tinged sputum enlarged cervical lymph nodes What is actinic chelitits? irritation of lips associated with scaling, crusting, fissure, white hyperkeratosis considered premalignant squamous cell skin cancer What is chancre? 60 | P a g e removal of all cervical lymph nodes from the mandible to the clavicle and removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory muscle on one side of the neck What should be assessed postop radical neck dissection? altered respiratory status wound infection potential bleeding What nursing interventions are important to implement for radical neck dissection? assess for stridor (upper airway obstruction) encourage coughing and deep breathing to prevent atelectasis and pneumonia What is gastritis? disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices What causes acute gastritis? dietary indiscretion medications alcohol bile reflux radiation therapy ingesting strong acid or base What causes chonic gastritis? benign or malignant ulcers of the stomach H. pylori What are signs of acute gastritis? epigastric pain dyspepsia anorexia hiccups (diaphragm irritation) nausea vomiting What are signs of chronic gastritis? fatigue pyrosis belching sour taste halitosis early satiety anorexia 61 | P a g e nausea vomiting What is peptic ulcer disease? erosion of the mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus associated with H. pylori infection What are signs and symptoms of peptic ulcer disease? dull gnawing pain burning in the midepigastrium heartburn vomiting What is the most common site of peptic ulcer formation? duodenum What are complications of constipation? decreased cardiac output from straining fecal impaction hemorrhoids commonly from straining and increased pressure fissures from straining rectal prolapse from straining megacolon Which is an example of a laxative osmotic agent? polyethylene glycol and electrolytes Rationale: Polyethylene glycol and electrolytes is an osmotic agent.Bisacodyl is a stimulant laxative. Ducosate is an emollient stool softener.Magnesium hydroxide is a saline agent. What is borborygmus? stomach rumbling (bubble gut) What is tenesmus? feeling of incomplete defecation What is irritable bowel syndrome? chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements (diarrhea, constipation, or both) What are manifestations of malabsorption? 62 | P a g e diarrhea frequent, loose, bulky, foul-smelling stools high-fat content in stool grayish in color What is a Schilling test for? determine B12 deficiency What is Celiac disease? disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten women are afflicted twice as often as men What is diverticulum? sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer What is diverticulosis? multiple diverticula without inflammation What is diverticulitis? infection and inflammation of diverticula What is peritonitis? inflammation of the serous membrane lining the abdominal cavity and covering the viscera caused by bacterial or fungal infection What causes primary peritonitis? it is commonly spontaneous usually from ascites What causes secondary peritonitis? bowel perforation What causes tertiary peritonitis? superinfection What assessment findings are associated with peritonitis? leukocytosis possible anemia dehydration acidosis abdominal x-ray may show free air and distended bowel loops abdominal ultrasound may reveal abscesses 65 | P a g e a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes Is the following statement true or false? Only persons with hepatitis B are at risk for hepatitis D. True Rationale: Only persons with hepatitis B are at risk for hepatitis D.Hepatitis D is common among those who use IV or injection drugs,patients undergoing hemodialysis, and recipients of multiple bloodtransfusions. Sexual contact with those who have hepatitis B isconsidered to be an important mode of transmission of hepatitis B andD. What vitamins are fat soluble? A, D, E, & K they are stored in the liver and fatty tissues What is vitamin A for? night and normal vision What is vitamin D for? works with parathyroid hormone to regulate absorption of and use of calcium and phosphorus What are the forms of vitamin D? calcifediol calcitriol (activated) ergocalciferol What is vitamin K for? synthesis of blood coagulation factors in the liver What are the vitamin K dependent clotting factors? factor II factor VII factor IX factor X What conditions are associated with vitamin B1 (thiamine) deficiency? Wernicke's encephalopathy and Beriberi What is vitamin C (ascorbic acid) for? maintenance of connective tissue tissue repair 66 | P a g e What does vitamin C (ascorbic acid) do? enhances absorption of iron it is required for synthesis of lipids, proteins, and steroids aids in cellular respiration aids in resistance to infection What does vitamin C (ascorbic acid) deficiency cause? scurvy What is calcium essential for? transmission of nerve impulses contraction of cardiac, smooth, and skeletal muscles renal function, respiration, and blood coagulation What is calcium deficiency called in children and adults? children = rickets adults = osteomalacia How do you calculate BMI? (weight (lbs) * 703)/(ht(inches)^2) During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A) Acquired immunity B) Natural immunity C) Phagocytic immunity D) Humoral immunity A) Acquired immunity Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth. A patients injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation? A) Eosinophils B) Red blood cells C) Lymphocytes D) Neutrophils 67 | P a g e D) Neutrophils Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation. A nurse is admitting a patient who exhibits signs and symptoms of a nutritional deficit. Inadequate intake of what nutrient increases a patients susceptibility to infection? A) Vitamin B12 B) Unsaturated fats C) Proteins D) Complex carbohydrates C) Proteins Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. As a result, the patient has an increased susceptibility to infection. Low intake of fat and vitamin B12affects health, but is not noted to directly create a risk for infection. Low intake of complex carbohydrates is not noted to constitute a direct risk factor for infection. A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? A) HIV encephalopathy B) B-cell lymphoma C) Kaposis sarcoma D) Wasting syndrome A) HIV encephalopathy HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations. We have an expert-written solution to this problem! The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient? A) Would you like me to have the chaplain come speak with you? 70 | P a g e An adolescent patients history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem? A) Bronchitis B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis D) Asthma D) Asthma Nurses should be aware that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, and RA. The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan? A) Risk for Disturbed Body Image Related to Skin Lesions B) Risk for Disuse Syndrome Related to Dermatitis C) Risk for Ineffective Role Performance Related to Dermatitis D) Risk for Self-Care Deficit Related to Skin Lesions A) Risk for Disturbed Body Image Related to Skin Lesions The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of patients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit. A patient is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the patient begins to exhibit signs and symptoms of a transfusion reaction. The patient is suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immunecomplex (type III) D) Delayed type (type IV) B) Cytotoxic (type II) A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient? A) Promoting adequate perfusion in affected regions 71 | P a g e B) Promoting safe use of topical antihistamines C) Identifying the offending agent, if possible D) Teaching the patient to safely use an EpiPen C) Identifying the offending agent, if possible Identifying the offending agent is a priority in the care of a patient with dermatitis. Antihistamines are not administered topically and epinephrine is not used to treat dermatitis. Inadequate perfusion occurs with PAD or vasoconstriction. A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? A) Type I B) Type II C) Type III D) Type IV A) Type I Urticaria (hives) is a type I hypersensitive allergic reaction A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern? A) Teach the patient to take deep breaths and cough frequently. B) Use antihistamines daily throughout the year. C) Teach the patient to seek medical attention at the first sign of an allergic reaction. D) Modify the environment to reduce the severity of allergic symptoms. D) Modify the environment to reduce the severity of allergic symptoms The patient is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions are anaphylaxis. Overuse of antihistamines reduces their effectiveness. A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone B) Methotrexate (Rheumatrex) 72 | P a g e In the past, a step-wise approach starting with NSAIDs was standard of care. However, evidence clearly documenting the benefits of early DMARD (methotrexate [Rheumatrex], antimalarials, leflunomide [Arava], or sulfasalazine [Azulfidine]) treatment has changed national guidelines for management. Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA. A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? A) Rheumatoid arthritis (RA) B) Systemic lupus erythematosus C) Osteoporosis D) Polymyositis A) Rheumatoid arthritis (RA) In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation. A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect? A) Infection B) Acute confusion C) Sedation D) Malignant hyperthermia A) Infection When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect. A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A) OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. B) OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees. C) OA originates with an infection. RA is a result of your bodys cells attacking one another. D) OA is associated with impaired immune function; RA is a consequence of physical damage. 75 | P a g e B) Altered serum calcium levels Serum calcium levels are altered in patients with osteomalacia, parathyroid dysfunction, Pagets disease, metastatic bone tumors, or prolonged immobilization. Pagets disease is not directly associated with altered magnesium, potassium, or sodium levels. We have an expert-written solution to this problem! A patient has had a cast placed for the treatment of a humeral fracture. The nurses most recent assessment shows signs and symptoms of compartment syndrome. What is the nurses most appropriate action? A) Arrange for a STAT assessment of the patients serum calcium levels. B) Perform active range of motion exercises. C) Assess the patients joint function symmetrically. D) Contact the primary care provider immediately. D) Contact the primary care provider immediately This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary. A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russells traction B) Dunlops traction C) Bucks extension traction D) Cervical head halter C) Bucks extension traction Bucks extension is used for fractures of the proximal femur. Russells traction is used for lower leg fractures. Dunlops traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck. A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites. B) Encourage the patient to push up with the elbows when repositioning. 76 | P a g e C) Encourage the patient to perform isometric exercises once a shift. D) Assess the pin insertion site every 8 hours. D) Assess the pin insertion site every 8 hours. The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome C) Compartment syndrome Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting. A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip. B) Patient is able to perform transfers safely. The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A) Deficient fluid volume B) Delayed wound healing C) Hypocalcemia D) Pathologic fractures 77 | P a g e B) Delayed wound healing Delayed wound healing is a complication of surgery due to tissue trauma from the surgery. Nutritional deficiency is usually due to the effects of chemotherapy and radiation therapy, which may cause weight loss. Pathologic fractures are not a complication of surgery. A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis? A) Increase calcium and vitamin intake. B) Perform meticulous foot care. C) Exercise 3 to 4 times weekly for at least 30 minutes. D) Take corticosteroids as ordered. B) Perform meticulous foot care. Diabetic foot ulcers have a high potential for progressing to osteomyelitis. Meticulous foot care can help mitigate this risk. Corticosteroids can exacerbate the risk of osteomyelitis. Increased intake of calcium and vitamins as well as regular exercise are beneficial health promotion exercises, but they do not directly reduce the risk of osteomyelitis. A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A) Calcitonin B) Prednisone C) Aspirin D) Cyclobenzaprine D) Cyclobenzaprine Short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. ASA is not normally used for pain control, due to its antiplatelet action and associated risk for bleeding. Calcitonin and corticosteroids are not used in the treatment of lower back pain. During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum B) Left midclavicular line of the chest at the fifth intercostal space 80 | P a g e the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment. A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this? A) To prevent bacterial endocarditis B) To prevent hospital-acquired pneumonia C) To minimize the need for antibiotic use during the procedure D) To decrease the need for surgical asepsis A) To prevent bacterial endocarditis Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis. A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A) The need for regularly scheduled testing of the patients International Normalized Ratio (INR) B) The need to learn to sleep in a semi-Fowlers position for the first 6 to 8 weeks to prevent emboli C) The need to avoid foods that contain vitamin K D) The need to take enteric-coated ASA on a daily basis A) The need for regularly scheduled testing of the patients International Normalized Ratio (INR) Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary. The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy C) Pulmonary edema As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the 81 | P a g e patients hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production. The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath A) Confusion and bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A) A beta-adrenergic blocker B) An antiplatelet aggregator C) A calcium channel blocker D) A nonsteroidal anti-inflammatory drug (NSAID) A) A beta-adrenergic blocker Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed. The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF? B) Patients with HF are susceptible to overstimulation of the sympathetic nervous system. C) Decreased LOC causes an exacerbation of the signs and symptoms of HF. D) The most significant adverse effect of medications used for HF treatment is altered LOC. A) HF ultimately affects oxygen transportation to the brain. 82 | P a g e As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular. A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A) Inflammatory bowel disease B) Intestinal polyps C) Diverticulitis D) Colon cancer A) Inflammatory bowel disease The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis. The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test? A) In a knee-chest position (lithotomy position) B) Lying prone with legs drawn toward the chest C) Lying on the left side with legs drawn toward the chest D) In a prone position with two pillows elevating the buttocks C) Lying on the left side with legs drawn toward the chest For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A kneechest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization. The nurse is preparing to perform a patients abdominal assessment. What examination sequence should the nurse follow? A) Inspection, auscultation, percussion, and palpation B) Inspection, palpation, auscultation, and percussion C) Inspection, percussion, palpation, and auscultation D) Inspection, palpation, percussion, and auscultation A) Inspection, auscultation, percussion, and palpation When performing a focused assessment of the patients abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation. 85 | P a g e A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, boardlike abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes. B) The patient has a rigid, boardlike abdomen that is tender. An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer. A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response? A) Administer a Fleet enema as ordered and remain with the patient. B) Contact the primary care provider promptly and report these signs of perforation. C) Position the patient supine and insert an NG tube. D) Page the primary care provider and report that the patient may be obstructed. B) Contact the primary care provider promptly and report these signs of perforation. The patients change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority. A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A) Insertion of a nasogastric tube B) Insertion of a central venous catheter C) Administration of a mineral oil enema D) Administration of a glycerin suppository and an oral laxative A) Insertion of a nasogastric tube Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present. The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? 86 | P a g e A) Drink fluids between meals but not with meals. B) Choose high-fat foods for at least 30% of intake. C) Developing flabby skin can be prevented by exercise. D) Choose foods high in fiber to promote bowel function. A) Drink fluids between meals but not with meals Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin. A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A) Keep patient NPO until the results of test are known. B) Keep patient NPO until the patients gag reflex returns. C) Administer analgesia until post-procedure tenderness is relieved. D) Give the patient a cold beverage to promote swallowing ability. B) Keep patient NPO until the patients gag reflex returns. After the examination, fluids are not given until the patients gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patients physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.