NUR 318 Focus on Adult Health Exam Questions & Answers

NUR 318 Focus on Adult Health Exam Questions & Answers . ID: 4 . A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply. A. Constipation B. Tall T waves Correct C. Hyporeflexia D. Shallow respirations E. Prolonged PR interval Correct F. Hyperactive bowel sounds Correct . Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia. . Test-Taking Strategy: The knowledge that spironolactone is a potassium- sparing diuretic will assist you in determining that hyperkalemia is an adverse effect of the medication. Recalling the manifestations of hyperkalemia will direct you to the correct options. Also, note that the incorrect options are comparable or alike in that they indicate a slowed body response or function. Review the adverse effects of spironolactone and the manifestations of hyperkalemia if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Assessment . Content Area: Adult Pharmacology . Giddens Concepts: Clinical Judgment, Fluid and Electrolytes . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes . Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. ) St. Louis: Saunders. . Awarded 3.0 points out of 3.0 possible points. . 2.ID: 8 . A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling “too full to eat.” What does the nurse encourage the client to do? Select all that apply. A. Avoid drinking fluids before and during meals Correct B. Eat a variety of dark-green vegetables, such as broccoli C. Have snacks, such as crackers and cheese, between meals D. Select foods that are easy to chew and are not gas forming Correct E. Consume high-calorie drinks, such as milkshakes, between meals . Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food, should be avoided. . Test-Taking Strategy: Use the process of elimination. Recalling that milk may increase the thickness of saliva will assist you in eliminating the option that encourages the consumption of milkshakes. Eliminate the option in which the consumption of broccoli is encouraged, because it is a gas-forming food. To select from the remaining options, note the strategic words “too full to eat” in the question and the option that encourages the client to avoid fluids before and during meals; this will direct you to the correct answers. Review dietary measures for the client with COPD if you had difficulty with this question. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Adult Health/Respiratory . Giddens Concepts: Gas Exchange, Nutrition . HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 595-596). St. Louis: Mosby. . Awarded 2.0 points out of 2.0 possible points. . 3.ID: 0 . A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image). . . The nurse documents the result of the test as: A. Positive Correct B. Negative C. Insignificant D. Indeterminate . Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease. . Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (negative and insignificant). To select from the remaining options, note that the client has HIV, which will assist in directing you to the correct option. An area of induration is present, so the test results are not indeterminate. Review the tuberculin skin test and the procedure for interpreting the results if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Assessment . Content Area: Adult Health/Respiratory . Giddens Concepts: Clinical Judgment, Evidence . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 494, 530). St. Louis: Mosby. . Awarded 1.0 points out of 1.0 possible points. . 4.ID: 6 . A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of: A. 4 cm H2O B. 8 cm H2O C. 11 cm H2O D. 14 cm H2O Correct . Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased. . Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the pathophysiology of right ventricular failure and recalling the normal CVP reading will direct you to the correct option. Review the normal CVP reading and the expected findings in right ventricular failure if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Assessment . Content Area: Adult Health/Cardiovascular . Giddens Concepts: Clinical Judgment, Perfusion . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. ). St. Louis: Mosby. . Awarded 1.0 points out of 1.0 possible points. . 5.ID: 4 . A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the bestway for the nurse to assess the surgical site for bleeding? A. Asking the client whether the dressing feels wet B. Looking for moisture on the top of the dressing C. Removing and replacing the dry sterile dressing every 2 hours D. Checking for moisture on the back of the dressing over the client’s neck and shoulders Correct . Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection. . Test-Taking Strategy: Note the strategic word “best.” Recalling the anatomical location of the surgical site will direct you to the correct option. Review care of the client after thyroidectomy if you had difficulty with this question. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Implementation . Content Area: Perioperative Care . Giddens Concepts: Clinical Judgment, Tissue Integrity . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1399). St. Louis: Saunders. . Awarded 1.0 points out of 1.0 possible points. . 6.ID: 4 . A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client’s needs for wound healing and tissue repair? Select all that apply. A. Apple slices and skim milk B. Whole-milk shake and granola Correct C. Baked potato topped with cheese Correct D. Cheese and whole-wheat crackers Correct E. Cauliflower with low-fat ranch dip . Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are preferable in this situation. . Test-Taking Strategy: Focus on the strategic words “wound healing and tissue repair.” Use your knowledge of the principles of nutrition in regard to tissue healing to answer this question. Remembering that the burned client’s diet should be high in calories, protein, and carbohydrates will assist you in answering correctly. If you had difficulty with this question, review the nutrition required for healing and tissue repair. . Level of Cognitive Ability: Understanding . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Implementation . Content Area: Nutrition . Giddens Concepts: Nutrition, Tissue Integrity . HESI Concepts: Metabolism – Nutrition, Tissue Integrity . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 467-468). St. Louis: Mosby. . Awarded 3.0 points out of 3.0 possible points. . 7.ID: 4 . A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis? A. Vitamin C B. Phosphorus C. Beta-carotene D. Calcium carbonate with vitamin D Correct . Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene is incorrect, because a client with hypoparathyroidism typically has an increased phosphorus level. . Test-Taking Strategy: To answer this question accurately, recall that the client with hypoparathyroidism is likely to have low calcium and high phosphate levels. This will direct you to the correct option. If this question was difficult for you, review the treatment measures associated with hypoparathyroidism. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Nutrition . Giddens Concepts: Client Education, Nutrition . HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. ). St. Louis: Mosby. . Awarded 1.0 points out of 1.0 possible points. . 8.ID: 4 . A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise healthy client. What should the nurse tell the client to do next? A. Seek treatment for diabetes mellitus B. Ask the health care provider about starting insulin therapy C. Consult with a nutritionist about foods that are high in cholesterol D. Call his health care provider to have these values rechecked as soon as possible Correct . Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than 140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client’s results is needed to ensure appropriate diagnosis and therapy. . Test-Taking Strategy: The strategic words in the question are “otherwise healthy client” and “next.” Eliminate the options that are comparable or alike in that the nurse makes a diagnosis or recommends a treatment. Choose correctly between the remaining options by recalling that that follow-up with a health care provider is required. Review these laboratory tests and the need for follow-up if you had difficulty with this question. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Implementation . Content Area: Adult Health/Endocrine . Giddens Concepts: Client Education, Health Promotion . HESI Concepts: Teaching and Learning/Patient Education, Health, Wellness, and Illness – Health Promotion . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 699-700). St. Louis: Mosby. . Awarded 1.0 points out of 1.0 possible points. . 9.ID: 3 . Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the medication. Which occurrences does the nurse tell the client to report to the health care provider? Select all that apply. A. Lethargy B. Chest pain Correct C. Palpitations Correct D. Weight gain E. Constipation F. Rapid heart rate Correct . Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain, palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium). . Test-Taking Strategy: Use the process of elimination. Recalling the classic symptoms of hypothyroidism, which the medication should relieve, will assist you in eliminating lethargy, constipation, and weight gain. Also, note that the incorrect options are comparable or alike In that they all reflect slowing of a body response or function. Review the client teaching points for levothyroxine sodium if you had difficulty with this question. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Pharmacology . Giddens Concepts: Clinical Judgment, Safety . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety: . Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 697) St. Louis: Saunders. . Awarded 3.0 points out of 3.0 possible points. . 10.ID: 5 . A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority for this client? A. Change in body image Incorrect B. Increased risk for injury Correct C. Increased risk of depression D. Lower level of physical activity . Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk of depression and change in body image are more psychosocial in nature and, as such, are secondary needs. A lower level of physical activity may be a problem but is not the priority. . Test-Taking Strategy: Focus on the subject, the consequences of diabetic neuropathy. Use Maslow’s Hierarchy of Needs theory and note the relationship between the word “neuropathy” in the question and “risk for injury” in the correct option. Review the consequences of diabetic neuropathy if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Analysis . Content Area: Adult Health/Endocrine . Giddens Concepts: Clinical Judgment, Tissue Integrity . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. , 1186). St. Louis: Mosby. . Awarded 0.0 points out of 1.0 possible points. . 11.ID: 2 . The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply. A. Shakiness Correct B. Drowsiness C. Blurred vision Correct D. Increased thirst E. Feelings of hunger Correct F. Nausea and vomiting . Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after administration. When the medication’s action peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger. The other options are signs and symptoms of hyperglycemia. . Test-Taking Strategy: Note the subject, the signs and symptoms of hypoglycemia. Recalling the pathophysiology of hypoglycemia will direct you to the correct answers. Review the signs and symptoms of hypoglycemia and hyperglycemia if this question was difficult. . Level of Cognitive Ability: Evaluating . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Evaluation . Content Area: Adult Health/Endocrine . Giddens Concepts: Client Education, Glucose Regulation . HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1175). St. Louis: Mosby. . Awarded 3.0 points out of 3.0 possible points. . 12.ID: 5 . Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply. A. It does not have a peak effect. Correct B. It is usually given once daily, at bedtime. Correct C. It usually has a 24-hour duration of action. Correct D. It may be mixed in a syringe with regular insulin. E. Its onset of action comes 4 hours after administration. . Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin. . Test-Taking Strategy: Knowledge regarding glargine insulin is required to answer this question. Review of the characteristics of glargine insulin if this question was difficult for you. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Pharmacology . Giddens Concepts: Client Education, Glucose Regulation . HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation . References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 624 ) St. Louis: Saunders. . Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care.(7th ed., p. 1431). St. Louis: Saunders. . ~ Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin. . Test-Taking Strategy: Knowledge regarding glargine insulin is required to answer this question. Review of the characteristics of glargine insulin if this question was difficult for you. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Pharmacology . Giddens Concepts: Client Education, Glucose Regulation . HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation . References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 624 ) St. Louis: Saunders. . Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care.(7th ed., p. 1431). St. Louis: Saunders. . Awarded 3.0 points out of 3.0 possible points. . 13.ID: 3 . A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads: A. 7.28 B. 7.30 C. 7.40 Correct D. 7.50 . Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40. . Test-Taking Strategy: Knowledge that the normal body pH is 7.40 will direct you to the correct option. pH values of 7.28 and 7.30 indicate acidic condition, whereas 7.50 indicates an alkaline condition. Review care of the client who has sustained a chemical splash to the eye if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Implementation . Content Area: Critical Care . Giddens Concepts: Clinical Judgment, Tissue Integrity . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity . Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 288). St. Louis: Elsevier. . American Family Physician , Ocular Emergencies. . Awarded 1.0 points out of 1.0 possible points. . 14.ID: 0 . A nurse educator conducts an informational session for emergency department nurses about smallpox. Which statements by the nurse educator are correct? Select all that apply. A. Smallpox is transmitted by way of the enteric route. B. Ealy clinical manifestations include influenza-like symptoms. Correct C. Vacinating within 3 days of exposure lowers the risk of active disease. Correct D. Th infected person is infectious from the onset of the rash until the scabs separate. Correct E. A difuse red rash noted over the entire body is the first manifestation of the infection. F. Airbrne precautions are not necessary if the nurse has received the smallpox vaccine. . Rationale: Clinical manifestations of smallpox include sudden onset of influenza-like symptoms, including fever, malaise, headache, prostration, severe back pain, and, less often, abdominal pain and vomiting. Two to 3 days later, the temperature falls and the client feels somewhat better, at which time the characteristic rash appears, first on the face, hands, and forearms and then, after a few days, on the trunk. Lesions also develop in the mucous membranes of the nose and mouth and ulcerate very soon after their formation, releasing large amounts of virus into the mouth and throat. Smallpox is transmitted from person to person in infected aerosols and air droplets, especially if the symptoms include coughing. A person is considered infectious at the onset of the rash and until the rash scabs over, which is approximately 3 weeks. Airborne precautions are required even if the nurse has been vaccinated against smallpox, because the vaccine does not give reliable lifelong immunity. Those vaccinated within 2 or 3 days of exposure have a lesser risk of active disease. . Test-Taking Strategy: Specific knowledge regarding the characteristics of smallpox is required to answer the question. Recalling its manifestations, the appearance of the rash, and the mode of transmission will help you answer correctly. Review the characteristics of smallpox infection if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Biological/Chemical Warfare . Giddens Concepts: Client Education, Infection . HESI Concepts: Infection, Teaching and Learning/Patient Education . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders. . Awarded 3.0 points out of 3.0 possible points. . 15.ID: 5 . A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply. A. Skin anthrax can lead to septicemia if it goes untreated. Correct B. Symptoms may appear as soon as 24 hours after exposure. Correct C. This type of anthrax results from the inhalation of spores. D. Contact precautions are not always necessary with skin anthrax. Correct E. Early clinical manifestations include mild upper respiratory symptoms. . Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person-to- person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue. . Test-Taking Strategy: Use the process of elimination and focus on the subject, skin anthrax. Eliminate the options that are comparable or alike in that they apply to inhalation anthrax. Review the characteristics of skin anthrax if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Biological/Chemical Warfare . Giddens Concepts: Infection, Safety . HESI Concepts: Infection, Safety . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders. . ~ Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person- to-person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue. . Test-Taking Strategy: Use the process of elimination and focus on the subject, skin anthrax. Eliminate the options that are comparable or alike in that they apply to inhalation anthrax. Review the characteristics of skin anthrax if you had difficulty with this question. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Biological/Chemical Warfare . Giddens Concepts: Infection, Safety . HESI Concepts: Infection, Safety . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders. . Awarded 3.0 points out of 3.0 possible points. . 16.ID: 8 . A nurse is conducting an admission assessment of a client hospitalized with a diagnosis of Meniere’s disease. Which question would elicit information specific to the attacks that occur with this disorder? A. “Are you having any headaches?” B. “Do you have difficulty speaking?” C. “Do you have a feeling of fullness in your ear?” Correct D. “Do you have momentary losses of consciousness?” . Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches, difficulty speaking, and momentary losses of consciousness are not associated with this disorder. . Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with Meniere’s disease to answer this question. Recalling that this disorder is associated with the ear will direct you to the correct option. If you are unfamiliar with Meniere’s disease, review this content. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Assessment . Content Area: Adult Health/Ear . Giddens Concepts: Clinical Judgment, Intracranial Regulation . HESI Concepts: Assessment, Intracranial Regulation . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 405-406). St. Louis: Mosby. . Awarded 1.0 points out of 1.0 possible points. . 17.ID: 6 . A nurse provides discharge instructions to a client who was hospitalized for an acute attack of Meniere’s disease. Which statements by the nurse are correct? Select all that apply. A. Unrestricted salt is allowed in the diet. B. Position changes should be made slowly. Correct C. Underwater swimming should be avoided. Correct D. It is best to switch to decaffeinated tea and coffee. Correct E. A glass of red wine in the evening will ease symptoms. F. If an acute attack occurs, sit down and keep the eyes closed. Correct . Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes. . Test-Taking Strategy: Use the process of elimination. Recalling that Meniere’s disease is an ear disorder and that it occurs as a result of a disturbance in the fluid of the endolymphatic system will direct you to correct options. If you are unfamiliar with the management of Meniere’s disease, review this content. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Adult Health/Ear . Giddens Concepts: Client Education, Intracranial Regulation . HESI Concepts: Intracranial Regulation, Teaching and Learning/Patient Education . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. ). St. Louis: Saunders. . ~ Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes. . Test-Taking Strategy: Use the process of elimination. Recalling that Meniere’s disease is an ear disorder and that it occurs as a result of a disturbance in the fluid of the endolymphatic system will direct you to correct options. If you are unfamiliar with the management of Meniere’s disease, review this content. . Level of Cognitive Ability: Analyzing . Client Needs: Physiological Integrity . Integrated Process: Teaching and Learning . Content Area: Adult Health/Ear . Giddens Concepts: Client Education, Intracranial Regulation . HESI Concepts: Intracranial Regulation, Teaching and Learning/Patient Education . Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. ). St. Louis: Saunders. . Awarded 3.0 points out of 4.0 possible points. . 18.ID: 7 . A client arrives at the emergency department and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to remove the insect? A. Instilling antibiotic eardrops Incorrect B. Instilling lidocaine into the ear Correct C. Using ear forceps to remove the insect D. Irrigating the ear with sterile saline solution . Rationale: Insects that make their way into an ear are killed before removal unless they can be coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration, worsening the impaction becomes worse. Antibiotics may or may not be prescribed after removal of the insect. . Test-Taking Strategy: Use the process of elimination and your knowledge regarding care of the client with a foreign body in the ear to answer this question. Note the strategic word “first,” which should direct you to the correct option. If you had difficulty with this question, review care of the client with a foreign body in the ear. . Level of Cognitive Ability: Applying . Client Needs: Physiological Integrity . Integrated Process: Nursing Process/Implementation . Content Area: Adult Health/Ear . Giddens Concepts: Clinical Judgment, Safety . HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 403). St. Louis: Mosby. . Awarded 0.0 points out of 1.0 possible points. . 19.ID: 2 . A home care nurse, assessing the skin of a client, notes the following rash beneath the skin: . . Which precaution will the nurse immediately institute before completing the assessment? A. Donning a mask and gloves B. Putting on a gown and gloves Correct C. Putting on a head covering and gloves D. E. F. Avoiding sitting on the client’s furniture G. . Rationale: Scabies presents as vesicle or pustule irritations, burrows, or rash of the skin, especially in the webbing between the fingers. When a client is infested with scabies, a gown and gloves should be worn for close contact. A mask and head covering are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by way of direct skin contact. All of the client’s contacts should be treated for the infestation at the same time. . Test-Taking Strategy: Remember the typical appearance of the scabies rash, then consider the mode of transmission of scabies and use the process of elimination. Because scabies is transmitted by way of direct skin contact, select the gown and gloves. If you had difficulty with this question, review the customary appearance of a scabies rash, standard precautions, and the mode of transmission of scabies. . Level of Cognitive Ability: Applying . Client Needs: Safe and Effective Care Environment . Integrated Process: Nursing Process/Implementation . Content Area: Infection Control . Giddens Concepts: Infection, Tissue Integrity . HESI Concepts: Infection,