Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing? A. Upper extremity flexion with lower extremity flexion B. Upper extremity flexion with lower extremity extension C. Extension of the extremities after a… Read More »
Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing: A. Hypovolemia B. Renal failure C. Metabolic acidosis D. Hyperkalemia Correct Answer: A. Hypovolemia In the diuretic phase fluid retained… Read More »
Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note: A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. B. Chest pain, dyspnea, cough, weight loss,… Read More »
Nurse Ron is assessing a client admitted with second and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. B. Urine output of 20 ml/hour. C. White pulmonary secretions. D. Rectal temperature of 100.6°… Read More »
A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute? A. Decreased HR B. Paresthesias C. Muscle weakness of the extremities D. Migraines Correct Answer: D. Migraines Migraines are not a symptom of… Read More »
Which of the following types of cardiomyopathy can be associated with childbirth? A. Dilated B. Hypertrophic C. Myocarditis D. Restrictive Correct Answer: A. Dilated Although the cause isn’t entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy of the first few… Read More »
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment? A. Palpate the spleen B. Take the blood pressure C. Examine the feet for petechiae D. Examine the tongue Correct Answer:… Read More »
A 22-year-old client suffered from his first tonic-clonic seizure. Upon awakening, the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic-clonic seizures in adults more than 20 years? A. Electrolyte imbalance B. Head trauma C. Epilepsy… Read More »
A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute? A. Vomiting B. Extreme Thirst C. Weight gain D. Acetone breath smell Correct Answer: C. Weight gain Rapid weight loss occurs in patients… Read More »
Septal involvement occurs in which type of cardiomyopathy? A. Congestive B. Dilated C. Hypertrophic D. Restrictive Correct Answer: C. Hypertrophic In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum – not the ventricle chambers – is apparent. Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease. It is defined… Read More »