Nokea
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
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A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply.
- A. Identify the problem at a staff meeting without placing blame on any individual or group.
- B. Ask the unit staff to develop a plan that they think will solve this problem.
- C. Ask an experienced nurse to spend time reorienting newer staff members.
- D. Collaborate with the staff development educator to develop a plan.
- E. Ask the neonatologist to give a presentation about assessing newborns.
Correct Answer: A,C,D,E
Rationale: Addressing the issue without blame, involving staff in solutions, reorienting newer staff, collaborating with educators, and arranging expert presentations are all effective strategies to improve documentation.
Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development?
- A. Identify clients at risk upon admission to the health care facility.
- B. Place at-risk clients on an every-2-hour turning schedule.
- C. Automatically place clients in specialty beds.
- D. Provide at-risk clients with a high-protein, high-carbohydrate diet.
Correct Answer: B
Rationale: Regular repositioning every 2 hours prevents prolonged pressure on skin, reducing the risk of pressure sores in at-risk clients.
A client is being treated with I.V. fluids for hypovolemic shock. Which of the following values is the best indicator that fluid resuscitation has been effective?
- A. Urine output of 30 mL/hour.
- B. Systolic blood pressure of 90 mm Hg.
- C. Respiratory rate of 22 breaths/minute.
- D. Pulse rate of 110 bpm.
Correct Answer: A
Rationale: A urine output of 30 mL/hour indicates adequate renal perfusion, a key sign of effective fluid resuscitation in hypovolemic shock.
A client with a diagnosis of gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse notices that which is the only food that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client's symptoms?
- A. Coffee
- B. Nonfat milk
- C. Fresh scrambled eggs
- D. Whole wheat toast with butter
Correct Answer: B
Rationale: Foods that increase the LES pressure will decrease reflux and lessen the symptoms of GERD. The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol and should be avoided in the diet of a client with GERD.