Medical Knowledge 2

Medical Knowledge 2

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

A. BP 146/88
B. Respirations 28 shallow ✔️
C. Weight gain of 10 pounds in six months
D. Pink complexion

Explanation: When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive.

Answers A, C, and D are within normal and, therefore, are incorrect.

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

A. “I will drink 500mL of fluid or less each day.”✔️
B. “I will wear support hose.”
C. “I will check my blood pressure regularly.”
D. “I will report ankle edema.”

Explanation: The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?

A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin’s disease as a teenager.✔️
D. The client’s brother had leukemia as a child.

Explanation: Radiation treatment for other types of cancer can contribute to the development of leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins, not siblings.

13. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

A. “Have you noticed a change in sleeping habits recently?”
B. “Have you had a respiratory infection in the last six months?”✔️
C. “Have you lost weight recently?”
D. “Have you noticed changes in your alertness?”

Explanation: The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous six months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

14. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

A. Oral mucous membrane, altered related to chemotherapy
B. ✔️Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member

Explanation: The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

15. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A. Sexual dysfunction related to radiation therapy✔️
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
D. Fatigue related to chemotherapy

Explanation: Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

16. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

A. Platelet count✔️
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)

Explanation: Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

17. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:

A. Bleeding precautions✔️
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy

Explanation: The normal platelet count is 120,000–400,000. Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

18. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

A. Place the client in Trendelenburg position for postural drainage.
B. Encourage coughing and deep breathing every two hours.
C. Elevate the head of the bed 30°.✔️
D. Encourage the Valsalva maneuver for bowel movements.

Explanation: A prolactinoma is a type of pituitary tumor. Elevating the head of the bed 30° avoids pressure on the sella turcica and helps to prevent headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

19. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

A. Measure the urinary output.
B. Check the vital signs.✔️
C. Encourage increased fluid intake.
D. Weigh the client.

Explanation: The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time

20. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

A. Place the client in a sitting position.
B. Administer acetaminophen (Tylenol).
C. Pinch the soft lower part of the nose.✔️
D. Apply ice packs to the forehead.

Explanation: C is correct because direct pressure to the nose stops the bleeding. Answers A, B, and D are incorrect because they do not stop bleeding.

21. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

A. The blood pressure✔️
B. The temperature
C. The urinary output
D. The specific gravity of the urine

Explanation: Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

22. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A. Glucometer readings as ordered✔️
B. Intake/output measurements
C. Evaluating the sodium and potassium levels
D. Daily weights

Explanation: IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

23. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

A. Obtain a crash cart.
B. Check the calcium level.✔️
C. Assess the dressing for drainage.
D. Assess the blood pressure for hypertension.

Explanation: The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling can be due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

24. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

A. Impaired physical mobility related to decreased endurance
B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia✔️

Explanation: The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

25. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?

A. Report muscle weakness to the physician.✔️
B. Allow six months for the drug to take effect.
C. Take the medication with fruit juice.
D. Report difficulty sleeping.

Explanation: The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

26. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

A. Utilize an infusion pump.
B. Check the blood glucose level.✔️
C. Place the client in Trendelenburg position.
D. Cover the solution with foil.

Explanation: Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.