Adult Health Developed by Dare Domico, RN, DSN Revised by Jill Ray

Adult Health

Developed byDare Domico, RN, DSN

Revised by Jill Ray

Integumentary Disorders

Practice Question 1

A client returns the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion?

1. Melanoma is the most common type of skin cancer.

2. Melanoma is often precipitated by pruritus.3. Melanoma is highly metastatic 4. Melanoma is characterized by local invasion

Practice Question 1A client returns to the clinic for follow-up treatment following a

skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion?

1. Melanoma is the most common type of skin cancer. Basal cell is the most common type.

2. Melanoma is often precipitated by pruritus. Can be part of the assessment findings for skin cancer.

3. Melanoma is highly metastatic highly metastatic – survival dependent upon early dx and tx.

4. Melanoma is characterized by local invasion can metastasize to the brain, lungs, bone, liver, skin….

Practice Question 2

Which lesion best represents Basal Cell Cancer?

1. 2.

3. 4.

Practice Question 2

Which lesion best represents Basal Cell Cancer? 1. Basal Cell 2. Mole

3. Squamous Cell

4. Melanoma

Basal Cell: Waxy border

Papule

Red, central crater

Metastasis rare

Squamous Cell:

oozing, bleeding, crusting lesion

Potentially metastatic

Larger tumors higher risk metastasis.

Melanoma:Irregular, circular, bordered lesion

Hues of tan, black, blue

Rapid infiltration into tissue, rapid metastasis.

A client has a superficial skin tear to the arm. The nurse applies which best type of dressing?

1.Dry sterile dressing

2.Wet-to-dry dressing

3.Gelfoam sponge dressing

4.Semipermeable film dressing

Practice Question 3

A client has a superficial skin tear to the arm. The nurse applies which best type of dressing?

1. Dry sterile dressing stick to the wound

2. Wet-to-dry dressing not necessary

3. Gelfoam sponge dressing type of enzyme dressing used to tx necrotic tissue

4.Semipermeable film dressing Op-site, duoderm. Allow tissues to heal underneath.

Practice Question 4

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate?1. Give the client small glasses of clear liquids.2. Keep the client NPO.3. Allow the client to have full liquids.4 Order the client a full meal with extra liquids.

Practice Question 4

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate?1. Give the client small glasses of clear liquids.2. Keep the client NPO. Maintain NPO because burn

injuries freq. cause paralytic ileus. Fluids could cause vomiting because of the effect of the burn injury on GI fx. Oral care to alleviate thirst is OK

3. Allow the client to have full liquids.4 Order the client a full meal with extra liquids.

Note that 1,3, and 4 are similar choices.

Practice Question 5

In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile:

1. Tongue blade2. 4 by 4 gauze pad3. gloved hand4. 4 by 4 soaked in sterile saline

In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile:

1. Tongue blade rough surface would be abrasive to the injured skin, and it is too small to be practical for use…

2. 4 by 4 gauze pad the dry gauze pad would stick to the injured skin

3. gloved hand allows for better contact and control of the amt of pressure being applied to the burn area. Allows the nurse to feel the surface blisters without breaking them.

4. 4 by 4 soaked in sterile saline OK – but the gloved hand allows for more precise application and minimal injury to the tissue.

Practice Question 6

A client is NPO and has a NG tube in place after suffering bilateral burns to the legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment?

1. Gastric pH of 32. Presence of hypoactive bowel sounds3. GI drainage that is guaiac negative4. Absence of abdominal discomfort

Practice Question 6A client is NPO and has a NG tube in place after suffering bilateral burns to the

legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment?

1. Gastric pH of 3 gastric pH should be maintained at 7 or greater using prescribed antacids and histamine h2 receptor-blocking agents. Lowered pH in the absence of fd or tube feedings can lead to erosion of the gastric lining and ulcer development. (Note that normal gastric pH is 1.5-3.5)

2. Presence of hypoactive bowel sounds expected as client is NPO and has suffered burn injury

3. GI drainage that is guaiac negative normal finding – means that it is negative for blood

4. Absence of abdominal discomfort WNL

Practice Question 7

A client is admitted to the emergency department following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as

1. Superficial thickness burn2. Superficial partial thickness3. Deep partial thickness4. Full thickness

Practice Question 7A client is admitted to the emergency department

following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as

1. Superficial thickness burn these burns are painful

2. Superficial partial thickness these burns are painful

3. Deep partial thickness wound surface red, dry, with white areas in deeper areas.

4. Full thickness involve epidermis, dermis, and some subcutaneous fat. Some nerve endings damaged – may be insensitive to touch with little or no pain.

Superficial Thickness burnInjury to the upper third of the dermis – bld supply to dermis is intact.

Mild to severe erythema (pin to red)

Skin blanches with pressure

Burn painful, tingling, eased by cooling

Discomfort lasts about 48 hrs – heals in 3-5 days

No scarring and skin grafts not required.

Superficial Partial-thickness Burn

•Edema present

•Mottled pin to red base, broken epidermis, with wet, shiny, weeping surface

•Burn painful, sensitive to cold air

•Heals 0-21 days with no scarring, minor pigment changes possible

•Grafts may be needed

•Injury deeper into dermis, bld supply reduced

•Large blisters may cover an extensive area

Deep Partial-thickness Burn

Deep Partial-thickness Burn

•Extends into dermis

•Blister formation usu not seen because dead tissue is thick and sticks to underlying viable dermis

•Wound surface is red and dry with white areas in deeper parts

•May/may not blanch, edema is moderate

•Con convert to full thickness if complications

•Heals in 3-6 weeks, scar results, skin graft may be necessary

Full-thickness Burn• Involves injury and destruction

of the epidermis ad the dermis; wound will not heal by re-epithelializaion, grafting may be required

• Appears as a dry, hard, leathery eshcar (burn crust or dead tissue that must slough off or be removed form the wound before healing can occur

•Appears as a waxy white, deep red, yellow, brown, black

•Injured are appears dry•Edema present under eschar•Sensation reduced or absent because of nerve ending damage•Healing takes weeks to months and dependent on adequ bld supply•Must remove eschar and split-or full-thickness skin grafting•Scarring and wound contractures likely

Deep full-thickness• Extends beyond the

skin into underlying fascia and tissues, damage to the muscle, bone, tendons

• Injured area appears black and sensation is completely absent

•Eschar is hard and inelastic

•Healing takes months and grafts are required

•Mortality rates are higher for children younger than 4•Debilitating disorders (cardiac, respiratory, endocrine, renal disorders occur and hinder healing)•Mortality rate is higher with preexisting disorder.

Practice Question 8

A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment.?1. Urine output of 40 ml/hour.2. Urine that is pale yellow.3. Urine specific gravity of 1.0324. Urine pH of 6.

A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment.?1. Urine output of 40 ml/hour. 30ml/hr is WNL, 40 is OK2. Urine that is pale yellow. Pale urine is normal –

would be dark and concentrated if not well hydrated3. Urine specific gravity of 1.032 (1.016-1.022)4. Urine pH of 6. OK – urine pH of 6 is adequate (4.5-8

WNL). Do not monitor urine pH to assess hydration.

Practice Question 9

A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort?

1. Take baths twice daily using a dilute solution of vinegar and water.

2. Avoid the use of astringents on the skin3. Avoid the use of emollients on the skin4. Purchase a dehumidifier for the home.

A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort?

1. Take baths twice daily using a dilute solution of vinegar and water. Warm bath or shower per day for 15-20 min with warm water and a mild soap followed immediately by the application of an emollient to prevent evaporation of water form the hydrated epidermis.

2. Avoid the use of astringents on the skin avoid alcohol, astringents, or other drying agents to the skin. tend to have a drying affect on the skin

3. Avoid the use of emollients on the skin need to incr use of emollients

4. Purchase a dehumidifier for the home. A dehumidifier would further dry room air.

Practice Question 10The evening nurse reviews the nursing documentation

in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?

1. Intact skin2. Partial-thickness skin loss of the epidermis3. Deep, crater-like appearance4. Presence of sinus tracts

Practice Question 10The evening nurse reviews the nursing documentation

in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?

1. Intact skin2. Partial-thickness skin loss of the epidermis3. Deep, crater-like appearance4. Presence of sinus tracts

Classification of Pressure UlcersI Nonblanchable erythema of the intact skin.

II Partial-thickness skin loss involving epidermis and /or dermis.

III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.

IV Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

Stage I(no skin loss)

Stage II(Shallow crater – involves epidermis

and/or dermis)

Stage III(Full thickness involving

damage/necrosis of subc. Tissue. Does not extend down through underlying

fascia)

Stage III or IV

Stage IV Full thickness skin loss with Full thickness skin loss with extensiveextensive destruction; tissue necrosis; or damage to destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.muscle, bone, or supporting structures.

Oncology

Practice Question 11The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply.

1. Cardiac tamponade2. Leukopenia3. Syndrome of inappropriate ADH4. Hypercalcemia5. Hypophosphatemia6. Tumor lysis syndrome

The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply.1. Cardiac tamponade could result from direct pressure

from a tumor, complication from chemo (decrease platelets increase chances of hemorrhage)

2. Leukopenia3. Syndrome of inappropriate ADH tumors can produce,

secrete, or stimulate substances that mimic ADH hormone – low serum Na levels result and can lead to seizures, coma, death

4. Hypercalcemia late manifestation of extensive malignancy

5. Hypophosphatemia6. Tumor lysis syndrome large quantities of tumor cells

are destroyed rapidly. Can lead to renal failure.

Practice Question 12

The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client.1. Avoid folic acid intake.2. Increase intake of oral fluids.3. Report symptoms of dyspnea.4. Report symptoms of hematuria.

Practice Question 12The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client?1. Avoid folic acid intake.2. Increase intake of oral fluids.3. Report symptoms of dyspnea. This

medication can cause cardio toxicity, cardiomyopathy, EKG changes. CHF (dyspnea, tachycardia, peripheral edema) and myocardial toxicity are potential adverse reactions.

4. Report symptoms of hematuria.

Practice Question 13A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? (Select all that apply)1. Avoid any needle sticks in the left arm.2. Avoid abduction & external rotation of left arm.3. Begin pendulum arm swings & full ROM immediately.4. Elevate left arm on pillows to prevent edema.5. Have all blood pressure readings taken on the right arm.6. Massage wound site with essential oils once incision has

healed.

A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? (Select all that apply)

1. Avoid any needle sticks in the left arm.2. Avoid abduction & external rotation of left arm. Gradual

abduction and external rotation of the affected arm is encouraged. May be more comfortable elevating the arm.

3. Begin pendulum arm swings & full ROM immediately. These activities are started after the incision has healed.

4. Elevate left arm on pillows to prevent edema.5. Have all blood pressure readings taken on the right arm.6. Massage wound site with essential oils once incision has

healed. No indication for this

Postoperative Mastectomy

• Gradual abduction and external rotation of the affected arm is encouraged.

• Avoid activities that might lead to the development of lymphedema

• Begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema.

• Active exercises, such as pendulum swings and wall climbing are started after the incision has healed


A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis?1. Use lemon-flavored glycerin swabs2. Apply antacid coating solutions and viscous

lidocaine3. Brush oral plaques off with a soft toothbrush.4. Have client swish mouth with weak hydrogen

peroxide solution

Practice Question 14A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis?1. Use lemon-flavored glycerin swabs could cause pain2. Apply antacid coating solutions and viscous lidocaine

Antacids, Benadryl, and viscous lidocaine have been mixed in equal proportions to use as a component of oral care.

3. Brush oral plaques off with a soft toothbrush. could cause pain

4. Have client swish mouth with weak hydrogen peroxide solution

Practice Question 15A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area?

1. Use mild soap and do not rub with abrasive materials.

2. Do not use any lotions on the area being treated.

3. Expose the area to sunshine to maximize healing.

4. Wear clothing and bras that support the area.

A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area?

1. Use mild soap and do not rub with abrasive materials. Skin being tx is fragile and easily damaged. Mild soap and thorough rinsing with warm water.

2. Do not use any lotions on the area being treated. A hydrophilic moisture lotion can be used if the skin becomes dry.

3. Expose the area to sunshine to maximize healing. The area cannot be exposed to sun

4. Wear clothing and bras that support the area. Clothing should be loose and nonbinding.


Which of the following is a priority nursing intervention for a client with a vaginal radium implant?

1. Clamp and drain the Foley catheter at intervals.2. Provide a high residue diet.3. Place the client in a semiprivate room.4. Raise the head of the bed no more than 20

degrees.

Which of the following is a priority nursing intervention for a client with a vaginal radium implant?

1. Clamp and drain the Foley catheter at intervals. 2. Provide a high residue diet. Good idea – maintain

optimal GI fx. Note that “4” is the BEST choice but that this is appro.

3. Place the client in a semiprivate room. No - Private room, private bath

4. Raise the head of the bed no more than 20 degrees. Once the implant is in place, important to keep in the exact location. HOB only raised slightly if at all after placement.

Practice Question 17The client is hospitalized for insertion of an internal

cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to

1. Call the MD2. Pick up the implant with gloved hands and

flush it down the toilet3. Reinsert the implant into the vagina

immediately4. Pick up the implant with long handled

forceps and place it in a lead container

Practice Question 17The client is hospitalized for insertion of an internal

cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to

1. Call the MD yes, but initial action is “4”2. Pick up the implant with gloved hands and flush it

down the toilet do not touch the implant3. Reinsert the implant into the vagina immediately

inappro action.4. Pick up the implant with long handled forceps and

place it in a lead container Key word is “initial” action.

Practice Question 18The nurse is caring for a client experiencing

Hematologic toxicity as a result of chemotherapy. The nurse develops a plan of care for the client. The nurse plans to

1. Restrict all visitors2. Restrict fluid intake3. Insert an indwelling urinary catheter to

prevent skin breakdown4. Restrict fresh fruits and vegetables in the

diet

Practice Question 18The nurse is caring for a client experiencing Hematologic toxicity

as a result of chemotherapy. The nurse develops a plan of care for the client. The nurse plans to

1. Restrict all visitors eliminate this choice because of the term “all”. The client is protected from persons with known infections.

2. restrict fluid intake unrealistic to restrict fluids in chemotherapy client who is at risk for fluid and electrolyte imbalance. Need to encourage fluids.

3. Insert an indwelling urinary catheter to prevent skin breakdown risk of infection, other noninvasive measures can be used if indicated

4. Restrict fresh fruits and vegetables in the diet immunocompromised client needs a low-bacteria diet. Includes avoiding fresh fruits and vegetables and thorough cooking of all foods.

Practice Question 19The client is diagnosed with benign prostatic hyperplasia and is

scheduled for transrectal ultrasound and drawing of a prostate-specific antigen level. The client says to the nurse, “ I can’t remember. Can you tell me again why I need these tests to be done?” The nurse responds knowing that the tests

1. Help to rule out the presence of cancer2. Specifically predict the course of benign prostatic

hyperplasia3. Pinpoint the likelihood of developing urinary

obstruction4. Give an indication of whether intermittent self-

catheterization is needed.

The client is diagnosed with benign prostatic hyperplasia and is scheduled for transrectal ultrasound and drawing of a prostate-specific antigen level. The client says to the nurse, “ I can’t remember. Can you tell me again why I need these tests to be done?” The nurse responds knowing that the tests

1. Help to rule out the presence of cancer 2. Specifically predict the course of benign prostatic

hyperplasia3. Pinpoint the likelihood of developing urinary

obstruction4. Give an indication of whether intermittent self-

catheterization is needed.diagnostic test do not predict the course of a disease – likelihood of developing complications (i.e. obstruction)


A nurse is reviewing the lab results of a client with leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets that the client is at risk for1. Infection2. Bleeding3. Anemia4. Dehydration

Practice Question 20A nurse is reviewing the lab results of a client with leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets that the client is at risk for

1. Infection 2. Bleeding platelets are low3. Anemia H/H low4. Dehydration SG of urine can evaluate; skin turgor;

Serum Na can suggest hydration status

Practice Question 21The client with cancer is receiving chemotherapy

and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care?

1. Ambulation 3 times daily2. Monitoring temperature3. Pad side rails and sharp corners of the bed and

furniture4. Monitoring for pathological fractures

The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care?

1. Ambulation 3 times daily important in the plan of care but not related directly to thrombocytopenia

2. Monitoring temperature monitoring for infection, important esp if dealing with a leukemia pt – not the best choice for a pt with thrombocytopenia.

3. Pad side rails and sharp corners of the bed and furniture thrombocytopenia indicates a decr in number of platelets in circulating blood – client is at risk of bleeding.

4. Monitoring for pathological fractures important in the plan of care but not related directly to thrombocytopenia


A nurse is caring for the 25-year-old client will undergo bilateral orchidectomy for testicular cancer. Which of the following statements by the nurse would be most helpful in exploring the client's concerns about loss of reproductive ability?

1. “Has the doctor told you that you will not be able to have children?”

2. “You must be sad that you won't be able to have children after surgery.”

3. “Do you feel that the doctor has told you all you need to know about the upcoming surgery?”

4. “Share with me any concerns about how this surgery will affect you in the future.”


A nurse is caring for the 25-year-old client will undergo bilateral orchidectomy for testicular cancer. Which of the following statements by the nurse would be most helpful in exploring the client's concerns about loss of reproductive ability?

1. “Has the doctor told you that you will not be able to have children?” yes/no

2. “You must be sad that you won't be able to have children after surgery.” yes/no

3. “Do you feel that the doctor has told you all you need to know about the upcoming surgery?” yes/no

4. “Share with me any concerns about how this surgery will affect you in the future.”

Endocrine

Pituitary GlandHypopituitarism• Decr secretion of:

– growth hormone, – gonadotropic hormones, – thyroid-stimulating hormone, – adrenocorticotropic hormone, anti-

diuretic hormone• Assessment:

– Obesity (GH, TSH)– Decr CO (GH, ADH)– Infertility, sexual dysfx

(gonadotropins, ACTH)– Fatigue, low BP (TSH, ADH, ACTH, GH)

• Tx– Emotional support– Hormone replacement– education

Hyperpituitarism• Incr secretion of

– Growth hormone– Other pituitary hormones may also

be involved…can see Cushing’s syndrome

• Assessment– Large hands/feet– Thickening /protrusion of the jaw– Arthritic changes– Visual disturbances– Diaphoresis– Oily, rough skin– Organomegaly– Hypertension– Dysphagia– Deepening of the voice

• Tx– Emotional support– Frequ skin care– Pain management for joint pain– Prepare for

radiation/hypophysectomy if planned

Syndrome of Inappropriate ADH(SIADH) vsDiabetes Insipidus

Diabetes Insipidus• Decr secretion of ADH (opposes Diuresis –

decre secretion would mean that the body would loose large quantities of fluid via the u/o)

• Assessment:– Polyuria (4-24 L/day), Polydipsia,

Dehydration– Inability to concentrate urine (sg 1.006 or

lower)– Fatigue, muscle pain, weakness, h/a– Postural hypotension, tachycardia

• Tx:– Monitor v/s and neuro and CV status– Safety: postural hypotension– Monitor electrolytes– Monitor I/O, wt, serum osmolality, urine

s.g.– Restrict foods, liqu that produce diuresis– Diabinese– Pitressin, desmopressin acetate– Medic alert bracelet

SIADH• Incr secretion of ADH (the body would

retain fluid)• Assessment:

– s/s fluid volume overload– LOC changes– Wt gain, anorexia, nausea, vomiting– Hyponatremia (dilutional)– Hypertension, tachycardia

• Tx– Monitor v/s– Safety: altered LOC– I/O, daily wt– Monitor electrolytes, serum/urine

osmolality,– Restrict fluid intake– Adm diuretics and IV fluids– Demeclocycline

Adrenal GlandAddison’s disease• Hyposecretion of adrenal cortex

hormones• Assessment:

– Lethargy, fatigue, muscle weakness

– GI disturbances– Wt loss– Menstrual changes/impotence– Hypoglycemia, hyponatremia– Hyperkalemia– Hypercalcemia– Postural hypotension– Hyperpigmentation of skin

• Cushing’s disease• Hypersecretion of glucocorticoids• Assessment:

– Muscle wasting, weakness– Moon face, buffalo hump– Truncal obesity, thin extremities– Wt gain– Hirsutism (females)– Hyperglycemia, hypernatremia– Hypokalemia, hypocalcemia – Hypertension– Fragile skin that easily bruises– Reddish-purple striae on the abd

and upper thighs

Thyroid GlandHypothyroidism• Decr secretion of T3 and T4• Decr rate of body metabolism• Assessment:

– Lethargy– Weakness, muscle aches,

paresthesias– Intolerance to cold– Wt gain– Dry skin, hair loss– Bradycardia– Constipation– Generalized puffiness/edema around

the eyes and face (myxedema)– Forgetfulness/loss of memory– Menstrual distrubances– Cardiac enlargement, CHF– Perhaps goiter

Hyperthyroidism• Incr secre of T3 and T4• Incr rate of body metabolism• Graves’ Disease common cause/Toxic

diffuse goiter• Assessment :

– Enlarged thyroid– Palpitations, cardiac dysrhthmias– Exophthalmos– Hypertension– Heat intolerance– Diaphoresis– Wt loss– Diarrhea– Smooth, soft skin, hair– Nervousness/fine tremors if hands– Personality changes such as

irritability/agitation/mood swings

Parathyroid GlandHypoparathyroidism• Decr secr of parathyroid

hormone (causes decrease in Ca and incr in phosphorus)

• Assessment– s/s of tetany– Hypocalcemia/

hyperphosphatemia– Numbness/tingling in the face– Muscle cramps/abd cramps– Positive Trousseau’s sign (carpal

spasm) or Chvostek’s sign (facial spasm)

– Hypotension– Anxiety, irritability, depression

Hyperparathyroidism• Hypersecr of Parathyroid

hormone (incr in Ca levels, decr in phos)

• Assessment:– Hypercalcemia,

hypophosphatemia– Fatigue, muscle weakness– Skeletal pain/tenderness– Bone deformities/pathological

fractures– Anorexia, nausea, vomiting,

epigastric pain– Wt loss– Constipation– Hypertension– Cardiac dysrhthmias– Renal stones


The ER nurse planning care for a client with a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome knowing that the hyperglycemia results from

1. increased use of glucose2. increased production of glucose.3. overproduction of insulin4. Over hydration

Practice Question 23The ER nurse planning care for a client with a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome knowing that the hyperglycemia results from

1. increased use of glucose this would cause hypoglycemia

2. increased production of glucose. Note that the stem asks for the cause of the hyperglycemia

3. overproduction of insulin this would cause hypoglycemia

4. Over hydration these pts suffer from dehydration

Diabetic Ketoacidosis vs Hyperglycemic Hyperosmolar Nonketotic Syndrome

DKA• Complication of Type I DM• Occurs with severe insulin

deficiency• Clinical manifestations:

hyperglycemia, dehydration, ketosis, acidosis

• Tx: – restore bld volume, – tx dehydration, – tx hyperglycemia, – correct electrolyte imbalance

• Monitor potassium levels

HHNS• Extreme hyperglycemia without

ketosis or acidosis• Occurs most often in individuals

with Type II DM• Ketosis and acidosis do not occur• Clinical manifestations: CNS

alterations, dehydration or electrolyte loss

• Tx:– Similar to DKA– Fluid replacement, correct

electrolyte imbalance,– Administer insulin– Rehydration alone may

decrease glucose levels


The client with diabetes has been instructed in the dietary exchange system. The client ask if bacon is allowed in the diet. Which response is most appropriate?

1. “Bacon is much too high in fat.”2. “Bacon is not allowed.”3. “One strip of bacon may be eaten if one

teaspoon of butter is omitted.”4. “Bacon may be eaten if you eliminate one meat

item from your diet.”


The client with diabetes has been instructed in the dietary exchange system. The client ask if bacon is allowed in the diet. Which response is most appropriate?

1. “Bacon is much too high in fat.”2. “Bacon is not allowed.”3. “One strip of bacon may be eaten if one

teaspoon of butter is omitted.”4. “Bacon may be eaten if you eliminate one meat

item from your diet.”


A client with type 1 diabetes reports recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin & exercise? “The best time for me to exercise is

1. in the afternoon.”2. after I eat.”3. after breakfast.”4. after my morning snack.”

Practice Question 25A client with type 1 diabetes reports recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin & exercise? “The best time for me to exercise is

1. in the afternoon.” NPH insulin peaks in 6-14 hours.

2. after I eat.”3. after breakfast.”4. after my morning snack.”


A client with type 1 diabetes reports vomiting & diarrhea with no food intake or medications for 36 hours. Which additional statement indicates a need for further teaching? “I need to

1. stop my insulin.”2. increase my fluid intake.”3. call the physician because of these

symptoms.”4. monitor my blood glucose every 3 to 4 hours.”

Practice Question 26A client with type 1 diabetes reports vomiting & diarrhea with no food intake or medications for 36 hours. Which additional statement indicates a need for further teaching? “I need to

1. stop my insulin.” Type I DM need to maintain routine schedule of insulin administration unless prescribed otherwise by MD. Note that BG often increases with stress/illness.2. increase my fluid intake.” should do this3. call the physician because of these

symptoms.” should do this4. monitor my blood glucose every 3 to 4 hours.”

should do this


A client with diabetes has a glycosylated hemoglobin A1C level of 9%. Based on this test result, the nurse plans to teach the client about the need to

1. avoid infection.2. take in adequate fluids.3. prevent hyperglycemia.4. prevent hypoglycemia.

Practice Question 27A client with diabetes has a glycosylated hemoglobin A1C level of 9%. Based on this test result, the nurse plans to teach the client about the need to 1. avoid infection.2. take in adequate fluids.3. prevent hyperglycemia. Goal for pt with DM is

less than 7.5 %. This value provides an estimate of BGL for the prior 3-4 months.

4. prevent hypoglycemia.

Pt without DM value should be 4-6%.


A nurse is providing instructions to a client newly diagnosed with diabetes regarding insulin administration. A mixture of NPH and regular insulin is ordered. Sequence the following steps of this procedure:

1. inject air equal to the amount of NPH insulin into the vial of NPH insulin.

2. inject air equal to the amount of regular insulin into the vial of regular insulin

3. draw up the correct dosage of regular insulin4. draw up the correct dosage of NPH insulin

1, 2, 3, 4

Practice Question 29A nurse is providing home care instructions to a

client with a diagnosis of Addison’s disease. Which statement by the client indicates a need for further instructions? “I need

1. to wear a Medic Alert bracelet.”2. to take daily medications for a limited period of

time.”3. an increased dose of glucocorticoid medication

during stressful minor illnesses.”4. to purchase a travel kit that contains cortisone.”

Practice Question 29A nurse is providing home care instructions to a

client with a diagnosis of Addison’s disease. Which statement by the client indicates a need for further instructions? “I need

1. to wear a Medic Alert bracelet.” true2. to take daily medications for a limited period of

time.” chronic disease will take meds from now on…

3. an increased dose of glucocorticoid true medication during stressful minor illnesses.”

4. to purchase a travel kit that contains cortisone.” true

Practice Question 30A client has returned to the unit following a

thyroidectomy complaining of tingling sensations around the mouth and in the fingers. The nurse would next assess the results of which serum lab study?

1. Sodium2. Potassium3. Calcium4. Magnesium

Practice Question 30A client has returned to the unit following a

thyroidectomy complaining of tingling sensations around the mouth and in the fingers. The nurse would next assess the results of which serum lab study?

1. Sodium2. Potassium3. Calcium because of accidental damage to the

parathyroid which regulates CA levels.4. Magnesium

Practice Question 31Which medication will the nurse have available

for emergency treatment of tetany in the client who has had a thyroidectomy?

1. Calcium chloride2. Potassium chloride3. Magnesium sulfate4. Sodium bicarbonate


Which medication will the nurse have available for emergency treatment of tetany in the client who has had a thyroidectomy?

1. Calcium chloride supplemental Ca is indicated if s/s of tetany develop.

2. Potassium chloride3. Magnesium sulfate4. Sodium bicarbonate


A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order?

1. Place flat with head and neck immobilized.2. Rectal temps only until discharge.3. Maintain endotracheal tube for 24 hours.4. Continuous mist of room air or oxygen.

Practice Question 32A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order?

1. Place flat with head and neck immobilized. Do not need to immobilize the neck.

2. Rectal temps only until discharge. Oral, axillary temps are OK

3. Maintain endotracheal tube for 24 hours. Not necessarily intubated.

4. Continuous mist of room air or oxygen. Humidity will asst to decr postop inflammation.


A nurse is caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase the priority nursing action is to prepare to

1. administer regular insulin IV.2. administer 5% dextrose IV.3. correct the acidosis.4. apply an electrocardiogram monitor.


A nurse is caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase the priority nursing action is to prepare to

1. administer regular insulin IV.2. administer 5% dextrose IV.3. correct the acidosis. True4. apply an electrocardiogram monitor.

Probably true


A nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse ensures that which medical equipment is at the bedside?

1. Underwater seal chest drainage.2. Tracheotomy set.3. Intermittent gastric suction.4. Cardiac monitor.

Practice Question 34A nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse ensures that which medical equipment is at the bedside?

1. Underwater seal chest drainage.2. Tracheotomy set. Surgery very close to

trachea. Postop swelling could close the airway and create the need for Tracheostomy.

3. Intermittent gastric suction.4. Cardiac monitor.

Practice Question 35The nurse is assessing a client with syndrome of

inappropriate antidiuretic hormone (SIADH). What would the nurse expect to find on the laboratory values?1. Serum sodium=150 mEq/L and low urine

osmolality.2. Serum potassium=5 mEq/L and low serum

osmolality.3. Serum sodium=120 mEq/L and low serum

osmolality.4. Serum potassium=3mEq/L and high serum

osmolality.

Practice Question 35The nurse is assessing a client with syndrome of inappropriate

antidiuretic hormone (SIADH). What would the nurse expect to find on the laboratory values?

1. Serum sodium=150 mEq/L and low urine osmolality. 2. Serum potassium=5 mEq/L and low serum osmolality.3. Serum sodium=120 mEq/L and low serum osmolality. SIADH

causes the body to retain water. The serum sodium will be low (dilutional hyponatremia) and the serum osmolality will be low. Note Na levels are 135-145.

4. Serum potassium=3mEq/L and high serum osmolality.

Syndrome of Inappropriate ADH (SIADH)

• Excessive Antidiuretic Hormone (ADH) is released.

• ADH hormone opposes diuresis – which means that water is retained even when the plasma (serum) osmolality is normal.

• As a result of extracellular fluid expansion, serum osmolality decreases.

• Na levels decline because of the excess fluid volume.

Practice Question 36A client has been receiving vasopressin therapy

for treatment of diabetes insipidus. What will the nurse evaluate to assist in determining the therapeutic response to this medication?

1. Urine specific gravity2. Blood glucose3. Vital signs4. Oxygen saturation levels

Practice Question 36A client has been receiving vasopressin therapy for

treatment of diabetes insipidus. What will the nurse evaluate to assist in determining the therapeutic response to this medication?

1. Urine specific gravity vasopressin alleviates polyuria by incr ADH secretion. Urine SG will incr as the urine is less dilute and will return to WNL

2. Blood glucose3. Vital signs4. Oxygen saturation levels

Gastrointestinal


A nurse is caring for a client following a cholecystectomy via an abdominal incision. What is the best position for this client?

1. Side-lying position, to prevent aspiration.2. Semi-fowler’s position, to facilitate breathing.3. Supine, to decrease strain on the incision line.4. Prone, to reduce nausea.

A nurse is caring for a client following a cholecystectomy via an abdominal incision. What is the best position for this client?

1. Side-lying position, to prevent aspiration.2. Semi-fowler’s position, to facilitate breathing. Note

that the incision for this procedure is high on the abdomen and postop pain/discomfort can hinder respirations (lung expansion)

3. Supine, to decrease strain on the incision line. 4. Prone, to reduce nausea.

Practice Question 38When teaching a client with hepatitis C who is

receiving interferon and ribavirin therapy, the nurse encourages the client to eat

1. small frequent meals, high in carbohydrates. 2. small frequent meals, high in proteins.3. 3 well balanced meals daily, high in

carbohydrates.4. 3 well balanced meals daily, but with

minimal fluid intake.

When teaching a client with hepatitis C who is receiving interferon and ribavirin therapy, the nurse encourages the client to eat

1. small frequent meals, high in carbohydrates. Small frequ meals are recommended because of the drug’s s/e of nausea, vomiting, fatigue.

2. small frequent meals, high in proteins.3. 3 well balanced meals daily, high in carbohydrates.4. 3 well balanced meals daily, but with minimal fluid

intake.

Practice Question 39The nurse is caring for a client who has a bleeding duodenal ulcer. Which of the following assessment data would indicate gastric perforation?1. Increasing abdominal distention and rigid abdomen2. Decreasing hemoglobin and hematrocrit with bloody

stools.3. Diarrhea with increased bowel sounds and

hypovolemia.4. Decreasing blood pressure with tacycardia and

disorientation.

The nurse is caring for a client who has a bleeding duodenal ulcer. Which of the following assessment data would indicate gastric perforation?

1. Increasing abdominal distention and rigid abdomen Perforation is characterized by incr distention and a “board-like” abdomen.

2. Decreasing hemoglobin and hematrocrit with bloody stools. May be seen with hemorrhage

3. Diarrhea with increased bowel sounds and hypovolemia. May be seen with hemorrhage

4. Decreasing blood pressure with tacycardia and disorientation. May be seen with hemorrhage


Which of the following interventions has the highest priority for a client following a esophagogastroduodenoscopy?

1. Assessing for the return of the gag reflex.2. Giving warm gargles for a sore throat.3. Monitoring complaints of heartburn.4. Monitoring the temperature.

Which of the following interventions has the highest priority for a client following a esophagogastroduodenoscopy?

1. Assessing for the return of the gag reflex. ABC’s

2. Giving warm gargles for a sore throat. Psychosocial

3. Monitoring complaints of heartburn.4. Monitoring the temperature. Important but

would be a later complication

Documents

Adult Health Developed by Dare Domico, RN, DSN Revised by Jill Ray